Article: Should People with Unhealthy Lifestyles Pay Higher Insurance Premiums? (Part 4)

We hope you enjoy the last part of this recent article from Medscape on the topic and debate of whether people with unhealthy lifestyles should pay higher health insurance premiums.  - Dr. Z

Article: Part 4

By: David R. Buchanan

A number of criteria have been proposed by Dubois and other analysts, which offer reasonable grounds for striking an ethically appropriate balance between completely ignoring unhealthy behaviors and appreciating the many barriers that make it difficult for individuals to live a healthy lifestyle. Four proposed standards help to inform the discussion.

Feiring (2008) and Pearson and Lieber (2009) propose that differentiated plans should be imposed only prospectively for voluntarily refusing to take any action to change one's unhealthy behaviors. With this standard, people would not be charged more for coming into a plan being overweight or smoking but for stating that they are not willing to try to do anything about them. Applying this standard would recognize that health status is patterned by social position while acknowledging that it is not "determined," that is, that the majority of poor people do not smoke, are not obese, do not drink excessively, and have some physical activity in their lives (arguably, with some quibbling at the margins), and therefore, that it is reasonable to ask others in the same position to do the same. This standard entails two stipulations: first, that the proposed voluntary action that would demonstrate the good faith effort to be a contributing member to the collective goal of using limited resources prudently is accessible, and second, that it is the effort, not the outcome, that counts. It is sufficient that the member enroll in a smoking cessation program or weight loss program and not necessary that they achieve abstinence or a BMI of 25 to avoid being penalized.

Second, members should be offered a range of options to fulfill their obligation to contribute to the good of the collective enterprise. Unfortunately, there is a high correlation among the most common behaviors that are used to define an unhealthy lifestyle: smoking, drinking, overweight, and sedentary. Rather than asking people to take action to address each of these problems independently, allowing people to choose the issue that they would like to address first demonstrates sympathy and solidarity with their efforts to overcome hardships. The measure also promotes the exercise of autonomy, which has also been linked with better health.

The third standard is setting limits on the range of behaviors that should be considered for inclusion as unhealthy. Members should not be required to change behaviors such as sexual behaviors, childbearing, sexual orientation, and participation in sporting activities that elevate risk of injury because the harm of proscribing them would far outweigh the benefits to be gained by their reduction or elimination.

Each of these standards needs further specification, so the final recommendation is to leave these details to be resolved through a procedural process, such as Daniels and Sabin's (1997) accountability for reasonableness. Insurance companies should be required to present a public rationale for meeting these standards, an accounting of the anticipated benefits, and an appeals process for exempting individual cases, with a public review and rating process.

As the contentious debates about health care reform at the state and national levels in the US have shown, a significant proportion of the American public demands that individuals be held accountable for the behaviors. They do not accept the strong egalitarian position that people are entitled to an equal share of the benefits irrespective of level of effort. With conscientious development, policies can be written that achieve an acceptable balance of principles that are fair to all involved. As various plans are enacted, it will be critical to examine the effects of such policies and how much good they actually accomplish.

Article: Should People with Unhealthy Lifestyles Pay Higher Health Insurance Premiums (Part 3)

Article- Part 3 (continued from previous post)

By: David R. Buchanan

The fact that covering the higher medical expenses of people with unhealthy lifestyles on an annual basis means that others in the same plan will have to forego other possible plan benefits (e.g., eye care, dental care; or higher pay raises) is the nagging rub that points to the larger issue of honoring a social contract based on mutual obligation and mutual responsibility. There is a general sense that, if everyone did not smoke, maintained a healthy weight, drank only in moderation, and got some regular exercise, plans would cost less and/or be able to pay for procedures that they cannot now afford. Is there an ethically acceptable means to achieve the goal of assuring that all members of a collective cooperative scheme are making a comparable, honest effort at doing that which is within their power to use limited resources prudently? What sorts of ethical considerations weigh against using financial incentives to remind people to be mindful of their obligations to one another?

Dubois identifies several important ethical concerns. The most significant is that charging people more will fall disproportionately on those who already have less. Without careful crafting, charging higher premiums may further stigmatize those who are more likely to feel bad about themselves already, and it may act as a further disincentive to obtaining medical insurance, thus, exacerbating existing health disparities. As Dubois notes, its implementation may also harm third parties such as dependent children; due to the inherent opportunity costs, paying for a child's braces, for example, may no longer be affordable in families of less financial means. Finally, Dubois points out that monitoring and enforcing compliance in such schemes will inevitably prove costly. (Again, by analogy, both divorce settlements and car accidents reports have moved towards no-fault claims, due to the high costs involved in seeking to assign or apportion blame.) He raises a couple of other issues that seem less compelling. Is it a form of state coercion? It depends. Whereas it is easy to imagine horribly intrusive requirements, it is equally possible to identify terms that may not be particularly bothersome. Is it a violation of an existing social contract or an infringement on a right to health care? There are a range of existing remedies that lessen the magnitude of these concerns (such as switching insurance plans or voting in the opposing political party).

For my purposes, an interesting point raised by Dubois is the ambiguous effect of such plans on the issue of social solidarity. Schmidt (2008) describes how German law pertaining to health insurance avers an inextricable link between personal responsibility and social solidarity. The relevant section of the act, titled "Solidarity and Personal Responsibility," reads,

In the spirit of a mutually supportive community [Solidargemeinschaft], the task of the statutory health insurance is to maintain, restore or improve health of the insured. The insured have co-responsibility for their health; through a health conscious way of living, taking part in appropriately timed preventative measures [and] playing an active role in treatment and rehabilitation, they should contribute to avoiding illness and disability and overcoming the respective consequences. (p. 200)

Here, the act of actively taking care of one's health is seen to be an expression of one's participation in contributing to a collective common good. Such schemes incentivize and reward those who behave in ways that benefit the collectivity as a whole. Conversely, however, these same plans can be seen to undermine social solidarity because such meritocratic elements may be viewed as primarily benefiting those who are already advantaged and by eroding traditional notions of giving without expectation of return. In short, the issue is whether plans can be devised that benefit the least well off and reinforce the sense of social solidarity.

Article: Should People with Unhealthy Lifestyles Pay Higher Health Insurance Premiums? (Part 2)

Article- Part 2:

David R. Buchanan

Dubois reviews three ethical grounds that have been used to justify charging unhealthy people more or charging healthy persons less. (Economists consider the respective approaches fungible, that is, equivalent and interchangeable, from a rational economic perspective.) The first is based on the principle of beneficence: Encouraging healthy behaviors reduces suffering, prevents social exclusion, promotes autonomy, and reduces the threat to social solidarity (in light of potential concerns about the "free-rider" problem, where someone is seen to benefit from a system without contributing a fair share). Dubois notes that this line of justification suffers from the familiar problems of paternalism, wherein the state/government or some third party (the insurance company) asserts that it knows what is in a person's best interests better than the person himself. Beneficence may not be sufficient to override the principle of respect for autonomy, which holds that people should decide for themselves how they want to live their lives (as long as it does not harm others, as discussed below).

Dubois devotes an entire section to challenging the claim of actuarial fairness, i.e., because it costs more to treat people who smoke, are overweight, are sedentary, and drink too much, it seems only fair that they should pay more for their coverage. Dubois argues that this position is empirically disputable, and if applied consistently, would raise thorny issues about similar issues, like genetic disorders, which most people would find ethically unacceptable (e.g., should a family with a child born with cerebral palsy be charged more, following the same logic of actuarial fairness?). In the US context, the question of actuarial fairness raises three points that deserve further discussion. First, there is an important distinction to be made between public and private insurance schemes. In a competitive market system, private insurance companies can offer differential plans, and in principle, potential buyers can decide whether they consider the contractual terms fair or not. The same is not true of government-run, single-payer plans, where the issue of discrimination against poor and minority people would be inescapable (because it is an empirically well-established fact that the health behaviors and indicators at stake are more prevalent in these groups). A variation of this concern arises with respect to the difference between employers who offer a number of insurance plan options versus those who offer only a single employer-funded plan. In the latter situation, the question of equal or differential plans should be an issue for bargaining, where the employees can decide how they want to represent their collective interests, as they deliberate about the relative weight that should be given to different ethical considerations. Finally, though there is increasingly convincing evidence that the total costs of treating people with unhealthy lifestyles over a lifetime is less than the total for healthy people (because unhealthy people die younger), it is equally clear that, on annual basis, unhealthy people use more medical services. This is relevant because, in the long-term, it would be in the financial interests of the collective insurance industry to ignore unhealthy behaviors because such behaviors would eventually save them money. However, due to relatively high turnover in employment and changes in health insurance plans in the US, individual companies cannot bank on these potential savings, and hence, they see it in their interests to promote differentiated plans to attain short-term savings. That said, the idea that charging people more can be ethically justified strictly on the basis of financial calculations appears thin, unappealing, and unconvincing to most people, as it seems to diminish the value of mutual caring and commitment to a cold cash nexus.

The third grounds that Dubois discusses as justification for charging people with unhealthy lifestyles more is founded on an implicit social contract. Dubois makes surprisingly short shrift of this approach, devoting only a single paragraph to this line of reasoning, and he casts it largely in terms of individual responsibility to make productive contributions to society or "cooperative schemes" (about which he suggests that insurance schemes may or may not qualify). Dubois quickly dismisses these grounds, asserting that such arguments would require a more comprehensive theory of justice or the good society to be tenable. It may perhaps be because he is writing from a European perspective, where Rawls (1971) may not have as much influence, but I think that it is precisely in terms of a social contract that most Americans are struggling to make sense of this issue. They argue about it in terms of a powerful tension between a sense of reciprocity and mutual obligation versus sympathy and understanding about the degree to which individual health status is beyond one's personal control. People want to believe that they can and do exercise some degree of control over their own health. At the same time, it is a rare person who is not cognizant of the fragility of the human condition and the capriciousness of being stricken by disease. Given that there will never be enough money to pay for all possible medical procedures for everyone (the US already pays 2–3 times the percentage of its gross national product for health care expenditures as other industrialized nations, with little to show for it), it is imperative to use limited resources fairly. The major challenge then is coming to terms with how much individuals should be held accountable for exercising control over various health behaviors and how much weight should be given to the social determinants of health (where poor health can be explained as the result of brute bad luck due to circumstances of birth, which a just society should strive to rectify). In addition, as Rawls reminds us, finding an appropriate balance needs to be tempered with justice considerations that give precedence to concern for those who are least well off.

Article: Should People with Unhealthy Lifestyles Pay Higher Health Insurance Premiums? (Part 1)

From The Journal of Primary Prevention

by: David R. Buchanan

This commentary sets the article by Dubois on the ethical justification for charging higher insurance premiums for people with unhealthy lifestyles in the context of US health care reform. It reviews the relevance and strength of normative concerns identified by Dubois about the acceptability of such differentiated "means-tested" plans. It identifies key issues involving whether certain health behaviors matter ethically, and if so, the grounds that would justify an obligation for people to take action. The article frames the answer in terms of the need to achieve an ethically acceptable balance between the principle of equality and principle of merit and concludes with four ethical standards to focus the terms of the debate.

Introduction

The article by Dubois that appears in this issue does an admirable job of pointing out the many ethical concerns raised by the increasingly common practice of charging different rates for health insurance premiums based on one's health behaviors (e.g., smoking) or health status indicators (e.g., BMI, blood pressure). In this commentary, I would like to set these issues in the context of health care reform in the United States in order to highlight key issues that might inform the terms of the debate about its ethical acceptability here. The central concern raised by Dubois is whether or how charging people with unhealthy lifestyles more for health insurance than people with healthy lifestyles can be ethically justified.

In the US (and other industrialized nations), there is tremendous concern about containing escalating health care costs, which consistently outpace inflation. A number of mechanisms have been implemented to try to control these perpetually rising expenditures. One means is the use of capitated health care plans such as health maintenance organizations. (In capitated plans, enrollees pay a set amount for a given year of coverage, where the provider must absorb any additional costs if the services provided exceed that amount.) Another is the growing practice of charging copayments for health care visits. Reliance on a competitive market system is praised by proponents for promoting efficiency, and therefore, cost-savings (with contentious empirical evidence; see, for example, Woolhandler et al. 2003; Aaron 2003). Denying coverage to people with existing disease conditions (e.g., cancer, AIDS) is another way for individual companies to contain costs. The article by Dubois addresses the normative issues involved in financially rewarding or penalizing members of an insurance pool for engaging or failing to engage in preventative behaviors. Underscoring the controversy, Pearson and Lieber (2009) note that the initial federal Health Insurance Portability and Accountability Act (HIPAA) mandated that all workers covered under an employer-sponsored health plan pay the same premiums regardless of health status. However, federal authorities finalized rules in July 2008 granting exceptions from HIPAA for certain wellness programs, where employers can now offer rewards or penalties of as much as 20% of the total cost of covering an employee. Is this ethically warranted?

As Dubois explains, charging more for unhealthy behaviors is a form of cost-shifting. Where capitated health care plans shift the burden of controlling costs onto the health care provider, health insurance plans prorated on the basis of health lifestyle shift a share of the costs from the insurance company to the consumer. Copayments for medical visits are another means of cost-shifting to the consumer, but they also illuminate important differences with the differentiated plans under discussion here. First, copayments are applied universally and unconditionally, in contrast to the sort of "means-tested" system of charging different rates depending on one's health behaviors or health status. Second, copayments are intended to discourage unnecessary use of medical services, where differentiated plans are intended to encourage the adoption of healthy behaviors. Requiring people to do something actively is generally considered more intrusive and more onerous than asking people to refrain from doing something. These two issues—whether everyone should be treated alike, or whether there are ethically salient characteristics that justify differential treatment, and whether there are ethical grounds for obligating people to take certain actions—lie at the core of the controversies surrounding this policy.

One option is no-fault health insurance. This has been the prevailing system until relatively recently, and it is consistent with the established medical ethos of refraining from passing judgment and treating patients irrespective of the cause of their condition. The alternative is to maintain that these behaviors matter ethically, and therefore, rates should be calibrated based on the principle of merit, charging people according to what they deserve or have earned. The ready analogy here is offering discounts to drivers with safe driving records. To anticipate, if one accepts that both positions have some validity, then the challenge becomes specifying the conditions that can achieve an ethically appropriate balance between these conflicting moral principles.

Article on Fat Grafting: Part 2

Brought to you by:

By Reporter: Vanessa Welch

MEDICAL BREAKTHROUGHS - RESEARCH SUMMARY:

BACKGROUND: According to plasticsurgery.com, fat grafting is a procedure where doctors remove a patient's own fat to re-implant it where it is needed. The fat is typically extracted from body parts like the abdomen, thighs or buttocks and injected into another area that requires "plumping," such as the face. When used as a facial filler, fat grafting can improve the creased and sunken areas of the face and add fullness to the lips and cheeks. 

FAT HELPS SOLDIERS: A team of doctors at the University of Pittsburgh School of Medicine has received $1.6 million from the Department of Defense to help wounded soldiers recover from facial injuries by using technologies based on the biology of fat tissue. "As many as 26 percent of wounded soldiers suffer some kind of facial injury, which can have a huge impact on quality of life," Dr. J. Peter Rubin, Chief of plastic surgery and Co-director at the Adipose Stem Cell Center at the University of Pittsburgh, was quoted as saying. "While we can reconstruct bony structures very well, it is the surrounding soft tissues that give people a recognizable face. This project will investigate how soft tissue grafting can more precisely restore facial form and improve the lives of our wounded soldiers." The research program involves the treatment of 20 soldiers with facial injuries. The use of fat grafting for serious facial injuries, such as those resulting from roadside bombs, is performed by using specially-designed devices and instruments for harvesting fat tissue and implanting it into regions of scarred tissue. "Fat grafting, or moving fat tissue from one part of the body to another, has been used as a cosmetic procedure for decades," Dr. Rubin said. "We are now applying this technology for reconstructive surgery to accurately restore facial form after battlefield injuries."
(SOURCE: University of Pittsburgh Press Release) 

HOW IT WORKS: Dr. Rubin first removes fat from a patient's abdomen or thighs. Then, the fat is processed. Tissue layers are separated from other fluids. Dr. Rubin then re-injects the concentrated fat into the injured area. This adds volume and smoothes it out. 

STEM CELLS: THE FUTURE OF FAT GRAFTING? The research team would ultimately like to know if adult stem cells, which are present in fat tissue, will prevent grafted fat from being reabsorbed by the body. Dr. Rubin's team has separated stem cells from other fat tissue in lab studies. Their goal is to eventually re-inject stem cell enriched tissue for even better results. European studies have shown fat grafts performed with tissue enriched by stem cells shows promise. However, no studies in the United States have proven its effectiveness.

Article on Fat Grafting: Part 1

 Brought to you by: 

By Reporter: Vanessa Welch

Jeremy Feldbusch was just 23 -- and deployed in Northern Iraq -- when his unit came under attack.

"A piece of shrapnel about an inch by an inch and a quarter thick penetrated the side of my right eye. That was the start of a different battle for me," said Jeremy Feldbusch. 

The attack left him blind, brain injured, and severely scarred. Doctor Peter Rubin is part of a University of Pittsburgh medical center team, researching new ways to precisely reshape injured faces using a patient's own store of fat. 

"That's our best replacement tissue after trauma or cancer therapy," said J. Peter Rubin, M.D., Chief of Plastic Surgery at Adipose Stem Cell Center.

Rubin removes fat from a patient's abdomen or thighs. Then, it's processed -- separating tissue layers from other fluids. He then re-injects the concentrated fat into the injured area -- adding volume and smoothing it out. One potential side effect? Grafted fat may be re-absorbed by the body. Ultimately, researchers want to know if adult stem cells -- present in fat tissue -- will prevent that. 

"We know that they will be stressed by the surgical procedure, and under the stress, they are capable of releasing different growth factors that can assist in the healing process." 

For now, patients like Jeremy Feldbusch are reaping the benefits of the research-even without super-charged fat tissue. Jeremy's sunken forehead-and large facial scar- are less noticeable.

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