Insurance Denial and Self-Influenced Health Problems

Insurance Denial and Self-Influenced Health Problems

The concept of health insurance has been an integral part of our culture for many years. It can be defined by the following: “A group of persons contributing funds to a common pool, usually held by a third party. These funds are then used to pay for part or all of the costs of a defined set of health services for the members of the pool. This third party can either be a governmental social security, a public insurance fund pool, employer-sponsored pool, or a private insurance fund pool” (Akal & Harvey, 2001, p.18). As anyone who has dealt with insurance companies knows, the process is rarely as simple as it may appear at first. It depends on a very delicate balance between input of funds, medical/health care expenses, the profit the insurance company must make, and other complicating factors. The apparent disruption of this balance causes parties to fear that the system is treating them unfairly. A current fear for a growing portion of the population deals with insurance coverage of individuals who have self-influenced health problems. Insurance denial for self-influenced health problems such as smoking, obesity, heart disease, and diabetes is directly applicable to the nursing profession and society as a whole. Both positive and negative views of the issue deal with the cost of health insurance and health care, ethics of the insurance system, and individuals taking incentive for their own health.

Background of Health Insurance Coverage

Health insurance companies have different ways of dealing with the individuals of self-influenced diseases. Individuals with conditions caused by things such as smoking, obesity, drinking, or substance abuse, are likely to fall into what is known as a high risk category which normally includes people with serious or chronic illnesses, self-influenced or not. These people are put into a government program which will allow an otherwise uninsurable person to get insurance (Achman & Chollet, 2001, p. 7). Each individual state has different legislation that governs who insurance companies can deny. In Washington State, for example, “insurers must sell to everyone except the sickest 8% of the state’s market consumers. The excluded population can enroll in the state high risk pool” (Achman & Chollet, 2001, p. 7).

Given the state standards for insurance denial, it is very difficult for insurance companies to turn down anyone based on a self-induced health condition. By looking at insurance quotes from large companies, it appears that only age and smoking increase an insurance premium. Smokers have an increase of approximately 15.5% to their monthly premium, while an increase in 15 years of age results in a 63.9 % increase in premium (BlueCross BlueShield Association, 2007).

In spite of this, it must be considered that insurance companies have other methods for reducing their risk of loss due to preexisting health conditions of new clients. One way is to exclude the preexisting condition from coverage. For example, a heavy drinker suffering from a recent history of liver damage can easily get coverage, but may be denied care relating to that specific condition. Through the Health Insurance Portability and Accountability Act (HIPAA), federal law ensures that this exclusion may last no longer than 12 months (Kriedler, 2007). There is another important state law that enables insurance companies to deny claims regarding alcohol consumption. The Uniform Accident and Sickness Policy Provision Law (UPPL) allows insurers to deny treatment if any alcohol has been consumed, even if the condition being treated is not causally related to alcohol use (Barclay, 2007). This means that anyone who consumes alcohol takes the risk of being denied coverage during the time in which alcohol is in their blood.

In considering the major categories of self-influenced health problems, the associated cost increase in medical expenses is important to look at. Obesity is the most dramatic, demonstrating an average 35% increase in service expenses and a 75% increase in medication expenses. Smoking comes in second, with an average 20% increase in service costs and a 25% increase in medication. Drinking problems and simply being overweight pose more negligible increases in cost (Sturm, 2002, p. 249). These cost increases constitute the basis for the controversy over whether or not it is ethical to insure or deny the individuals who induce their own health problems.

Positive View of Health Insurance Denial

The American society places a high value on human life, and generally wants and expects quality medical care. Health insurance is one of the top concerns of the American people today. There have been many different attempts to curb spending. In the 1990’s, insurance companies restructured their payment schedules, and attempted to bring business savvy to the health industry in hopes that competition for business would keep the price of healthcare manageable (Chitty, 2005, p. 414). This leaves the country asking a significant question: “Is health care a privilege or a right?” With the costs for health insurance on the rise, it is important to look at the diseases that are avoidable and are costing Americans trillions of dollars a year. The American people pay a variable amount of money to cover themselves for the unseen health issues they may encounter. While it seems that health insurance should assist in paying for health conditions to which we have no control, what about diseases caused by the person? Should someone who purposefully engages in acts that are known to cause bodily harm, increasing health issues and decreasing life span, be covered the same as another who does not? Cigarette smoking, excessive alcohol consumption, unhealthy diet and lack of exercise are all contributors to diseases that could easily be avoided. Cardiovascular disease, obesity, and type II diabetes all affect Americans in the pocketbook and in personal well being each year. In order to have our patients truly embrace autonomy and take their health in their own hands, insurance should not have to pay for self-influenced diseases.

In 1980, the United States spent 8.7% of its gross domestic product (the value of all goods and services produced per nation) on health care (Edelman, 2006, p. 62). In 2000, health care expenditures accounted for 13.2%, $1.3 trillion of the gross domestic product (Wexler, 2003, p. 79). According to Edelman (2006), “The United States spends far more on health care than any other industrialized country” (p. 61). It is easy to say that the government or employers pay for health insurance, but the bottom line is that we the American people pay for health insurance. With our tax dollars, our consumer dollars, or our time at work, we all pay for health insurance. In 2002, private insurance paid for 35% of our health care costs, while Medicare, Medicaid and SCHIP accounted for 33%. Out of pocket expenses only paid for 14% of the total health care costs (Edelman, 2006, p. 63). With such a small percentage coming from personal funds, it is difficult for the client to feel the rising crunch of health premiums. The problem with our current health insurance system is that there is no incentive to worry about taking care of one’s own health because any consequences to a person’s unhealthy lifestyle are not followed by fiscal accountability. Having insurance companies and the governmental health insurance agencies pay for health conditions related to lifestyle habits fosters a dependence on the insurance system and does not allow consumers to truly become motivated to choose a healthier lifestyle.

According to Wexler (2003), Cardiovascular disease is the primary cause of death, which killed almost 168,000 Americans in 1999 (p. 55). This disease encompasses many other diseases which lead to costly complications throughout life. CV disease can be treated in many ways, including coronary artery bypass graft surgery, angioplasty, and transplants. In 1999, 571,000 coronary artery bypass graft surgeries were performed at $35,000, costing Americans about $19 billion (Wexler, 2003, p. 56). The less expensive alternative, angioplasty, was performed more than 601,000 times in 1999. This procedure’s cost totaled almost $15 billion in the year 1999.

Another example of why individuals should be denied health insurance for self-induced health problems is concerned with cigarette smoking. Cigarette smoking, a known carcinogenic, is perhaps the most controversial insurance risk. It can be said that the previous generation didn’t know the risks of smoking, but in this era there is no excuse. Today, most people are aware of the detrimental effects of tobacco. However, “cigarette smoking continues to be a leading cause of death in the United States. Although studies show that the numbers have decreased dramatically for smokers (48% since 1965), “almost half a million Americans die each year from smoking-related illnesses” (Wexler, 2003, p. 58). Additionally,

From 1995 to 1999, smoking killed over 400,000 people each year… Cigarette smoking is a direct cause of ischemic heart disease, respiratory heart disease, aortic aneurysm, chronic obstructive lung disease, stroke, pneumonia, cirrhosis, and cancer of the liver. Excluding deaths from second hand smoke, males and females lost an average of 31.2 and 14.5 years of life, respectively. Smoking during pregnancy results in an estimated 599 male infant and 408 female infant deaths annually (Huether, 2004, p. 254).

Although there are risk factors that are unchangeable, cigarette smoking nearly doubles the risk of a heart attack. Additionally, 30% of the annual mortalities resulting from coronary artery disease are traceable to cigarette smoking (Huether, 2004, p. 657). Once one has stopped smoking, no matter how long they have smoked, the risk of heart disease decreases dramatically. It is a voluntary lifestyle choice, and since the effects of cigarette smoking are well known, people who choose to smoke are truly taking their life into their own hands. While it is true that less and less Americans are smoking every year, the overall percentage of smokers is about one third. That third of the population is incurring a much larger health bill than the rest of the general population.

Heart disease, hypertension, and type II diabetes are linked together through another pressing American issue: Obesity. Caused by poor diet, lack of physical fitness, and the harried existence of American Culture, America is mired in fat. “In the United States, the incidence of adult obesity increased from 25% in the 1970’s to 64.5% in 2004” (Edelman, 2006, p. 16). There are many different theories as to why people are obese. The clinical manifestations of obesity are as follows:

Obese individuals are at risk for a number of disorders, including coronary artery disease, diabetes, gallstones, hypertension, cardiovascular disease, breast, cervical, endometrial and liver cancer in women; prostate, colon, and rectal cancer in men. Pulmonary function can be compromised by a large amount of adipose tissue overlying the chest cage. Gas exchange, vital capacity, and expiratory volume all decrease, causing low arterial oxygen tension and high carbon dioxide tension (Heuther, 2004, p. 1000).

Statistics show that,

Diabetes type 2 mellitus accounts for 90% to 95% of all diagnosed cases of diabetes… [It] is one of the leading causes of death among Americans and the leading cause of new cases of blindness, kidney failure, and lower extremity amputations, plus it greatly increases a person’s risk for a heart attack or stroke. In 2002 diabetes accounted for more than $132 billion in direct and indirect medical costs and lost productivity (Edelman, 2006, p. 255-6).

With our aging population and rising health care expenses, this is a cost the American people cannot afford to pay. The responsibility again is on the health insurance companies to pay for the results of disease.

Self-influenced diseases are a gray area of health care. They are influenced by the person’s environment, and can be controlled. While a person may have a genetic predisposition for a certain disease, a person's lifestyle can determine whether or not a disease will display. An example is Diabetes Type 2 Mellitus. A lifestyle in which a person eats appropriately and is physically active is less likely to express symptoms than a person who is sedentary who eats a high sugar, high fat diet. Is it the job of the health care industry to pay for every disease? America is torn between whether insurance is a right or a privilege. Currently, it is both. If you can afford health care, it is a privilege. If you are poor, it is a right. However, for the middle class, who make too much to qualify for Medicare/Medicaid and too little to afford private insurance, health care and health insurance is often merely a dream. Rather than look to health care for solutions to self-induced health problems, Americans should begin to take responsibility for their own health. If insurance will not cover diseases related to diabetes type II mellitus, then exercise and healthy diet begin to serve as a better alternative. If smoking related health causes are not covered, then rates of smoking cessation will improve. Whether we realize it or not, we are paying for everyone’s health care with our own money. It is time for Americans to take their health into their own hands, and advocate for healthier lifestyle choices, instead of footing the bill for gastric bypass.

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