Coverage And Common Sense

The debate continues regarding the best future for America’s health care system. Many so-called experts say health care costs will continue to rise faster than overall spending regardless of whether the Affordable Care Act stays in place or is replaced by something else.

One aspect of the health care debate rarely given serious attention is the role consumers have in restraining costs. In the past I have compared health insurance to a new car warranty. A new car warranty covers defi ned services for a certain period or number of miles and that warranty gives the consumer peace of mind should something major go wrong with the car.

For the warranty to be valid, though, the consumer must follow a specifi ed maintenance program. Otherwise, the consumer is on the hook for any needed repairs that would have been covered by the warranty. That makes sense because it gives the consumer some responsibility for keeping the car in good condition.

With health care insurance, there is no similar personal responsibility. It is irrelevant when it comes to coverage whether aninsured patient takes proper care of himself or chooses to ignore medical advice or engages in behavior clearly contrary to good health. A person with a known acute or chronic condition given sound medical advice by his physician can choose to ignore the advice, yet expect the highest level of care with full insurance coverage when showing up in an emergency room with an emergency related to the same condition. I feel the effect of this unnecessarily adds billions of dollars a year to the country’s overall health costs.

Another example: A motorcycle rider without a helmet has a life-threatening accident causing a head injury, yet gets full treatment and coverage despite the poor judgment of not using a helmet. Other examples include people with lung cancer who continue to smoke or people with a serious illness who refuse to take prescribed medications needed to treat the illness.

Should these people expect that their insurance policies will provide full coverage despite their lack of eff ort?

I believe in free choice.

The consumers should have the right to do what they want. They can ignore medical advice or, in the case of the motorcycle driver, common sense.

But there should be consequences for their decisions. They should not get a free ride when it comes to covering their health care bill when they make risky decisions.

On the other hand, the consequence should not be overly punitive. They should not be denied coverage entirely and suffer severe fi nancial consequences, but they should feel the pinch by being responsible for some portion of the bill due to their decisions.

This is not a simple matter and few consumers come close to being perfect in their healthrelated behavior. People with weight problems rarely become skinny and people with chronic health problems rarely see those problems go away. But such people can use some degree of common sense to help themselves, especially when they have been advised professionally that their condition will not improve or will worsen without some modifi cation of behavior. The goal is in the journey, not the destination.

How would this personal responsibility be measured or accounted for? Obviousabuses could be handled at the point of treatment through a higher coinsurance for that episode of care. Or the person’s insurance premium could have a surcharge in the future based on past history. Implementation would be a challenge but would be feasible and the benefit would be well worth it.

This idea is not intended in any way to be punitive to consumers. Many people already accept a high level of personal responsibility for their care. Nor is it intended to penalize people for failing to attain lofty goals. Rather, it is intended to get the attention of the segment of the population who unashamedly disregard doing things that could prevent or limit disease, yet who expect the health care system to foot the bill.

These costs eventually are redistributed to the rest of the population through higher premiums, so in the end we all pay more. This idea also is not intended as a stand-alone solution.

It needs to be part of an integrated system of improvements to address access to care, payment methods with the right incentives and other costcontainment solutions.

TOM O’NEAL IS A RETIRED HEALTH CARE EXECUTIVE WHO LIVES IN BELLA VISTA.

Opinion, Pages 5 on 09/22/2012

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