Nobody's Fault But Mine

(Disclaimer: I personally favor a nationalized, single-payer system of health care. I believe the recent health-care reform was a step in the right direction but nowhere near comprehensive enough.)

There’s more news out today about the climbing costs of health care. As I read more and more about insurance companies short-changing patients, I think more and more, “How can we reform the system?” I have an idea (theoretical only) that so depends on personal responsibility that I cannot believe some junior Republican congressman has not yet conceived of it: make medical insurance fault-based.

           

Within the United States of America, individual states use two different systems of car insurance: fault and no-fault. 38 states currently use a fault-based system in which a car insurer will pay out compensation according to each party’s degree of fault. Fault-based states allow for tort lawsuits by one driver against another, one driver against the other’s insurer, or by the insurer against its covered driver. In no-fault states a claimant does not have to prove that he did not cause the crash before collecting benefits.

           

Although less clear cut, the same principle applies in other insurance situations. If you burn down your house, you probably won’t collect compensation from your homeowner’s insurance policy. If a potential life insurance beneficiary murders the policy holder, as happened in the classic film noir Double Indemnity, the murderous spouse or child ain’t getting nothing.

           

Why not apply this principle to the medical insurance field? If you are at fault in getting sick or hurt, you have to pay out-of-pocket. It doesn’t even have to be black and white. Insurers could adopt the concept of “comparative fault” from tort law—a person’s medical benefits are reduced in proportion to his degree of fault in causing his medical complaint.

           

Let’s use an example. Three fifty-year-old men of similar weight and ethnicity are all diagnosed with State IV lung cancer. Patient #1 runs three miles every day. He sees his doctor regularly for check-ups. He eats all organic food. Yet for some mysterious reason, he gets lung cancer. Patient #2 started smoking at age 15. He tried several methods of quitting over the years but just couldn’t stop. Finally, with a doctor’s assistance, he managed to stay off cigarettes for the past 10 years. Still, he gets lung cancer. Patient #3 also started smoking at age 15, but he never even tried to quit. He gets lung cancer.

           

Assume all three have the same insurance coverage. Should there be a difference in the amount of out-of-pocket expenses? If we as Americans believe in personal responsibility and individuality, then yes, there should be a difference. Just as drivers must take responsibility for their individual driving records when paying insurance premiums, shouldn’t individuals take responsibility for their individual choices when insurance payouts are on the line?

           

I can hear the protests: “But Kristina, people do have to pay higher health insurance premiums if they’re unhealthy!” True, but the reason for their unhealthiness does not come into play. If Republicans really want to fix the fairness of the health-care system, they should look more closely at the reason a given individual is unhealthy.

           

Take another example: exclusively genetically-based medical conditions. Many medical conditions, most of them quite rare, are unequivocally not the fault of an individual because they are exclusively genetically-based, and yet people with these genetic conditions must still pay higher health insurance premiums or may have difficulty obtaining coverage at all. And all this based on something over which they have no control! This runs completely counter to the mantra of “personal responsibility.” Yes, charge higher premiums to the unapologetic smoker who refuses to even attempt to quit. Make him pay completely out-of-pocket for his lung cancer treatment. The drunk driver who wraps his car around a tree and injures himself should not get the privilege of public dollars. But do NOT make individuals with genetic illnesses pay for something they did not cause!

           

This idea works theoretically, but it runs into very practical problems. The unrepentant smoker (or irresponsible drunk driver) and the child with a genetic illness occupy opposite ends of the spectrum, and in their cases assigning levels of fault is very easy. For most other health complaints, however, doctors cannot accurately pinpoint whether nature or nurture caused the problem. Both genetic and environmental factors play a role in most medical issues, and determining the relative influence of those factors still vexes medical science. Some individuals will have high blood pressure no matter how much exercise they get and how many Omega-3s they ingest. Some obese individuals attempt valiantly to lose weight but just can’t keep it off. And the source of some individuals’ issues runs all the way back to childhood eating habits learned at the parental table. Should we blame adults for the mistakes their parents made during their youths?

           

So yes, apportioning blame is a hard task, especially in the field of human medicine. We do not yet know enough about the delicate balance of genetic and environmental factors. And yet lay juries apportion blame every day in car accident cases and medical malpractice cases. The jury members, who couldn’t think up an excuse to avoid jury duty and are likely dumb as rocks (or old as rocks), must decide whether a doctor’s actions fell below the professional standard of care and must determine whether Driver A ran a light or Driver B was distracted. The modern trend in these tortious settings is toward the system of “comparative fault.” Yes, the doctor may have failed to stitch the wound correctly, but the patient disobeyed direct instructions not to run around. Damages are adjusted accordingly.  

           

A fault-based medical insurance system could also accommodate a role for effort. An individual would get points for trying to quit smoking, for losing even 10 pounds, for bringing blood pressure down, and for regular preventative care. The smoker who attempts to quit but fails would pay less than the smoker who never even attempts. This creates incentives for individuals to take personal responsibility for themselves.

           

And of course, a fault-based system would have an exception for a natural part of life still bizarrely classified as a medical “condition:” pregnancy. Pregnancies, at least if you believe in science and do not read the Bible literally, tend to come about because of very specific human action.

           

Then there’s the big question of healthcare for senior citizens. Is aging your own fault? Admittedly, a fault-based system of health insurance would not solve the problem of ballooning costs for medical coverage for the elderly. We must continue to look elsewhere for a route out of that labyrinthine mess.

Republicans currently want to deny medical care for anyone who gets sick regardless of the causes of illness. Democrats currently want to give medical care to everyone regardless of the cause of complaints. True compromise on this subject requires an inquiry into the reasons people require medical care. Republicans chant their mantra of “personal responsibility” all day, but in this area they fail to see a golden opportunity to actually apply their theoretical position to a real-world problem.