Is There a Moral Duty to Buy Health Insurance?

July 15, 2012
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This question was answered in the affirmative by Tina Rulli, Ezekiel Emanuel, and David Wendler in the July 11, 2012 issue of JAMA.  Let me take you through their arguments.

They start by saying that “individuals have a moral duty to rescue.”  That is, we should provide aid to folks in urgent need as long as it “involves minimal risk and burden.”  They didn’t provide a reference for this statement, so I thought I would try to see if there is a literature to support this declaration.

This question was answered in the affirmative by Tina Rulli, Ezekiel Emanuel, and David Wendler in the July 11, 2012 issue of JAMA.  Let me take you through their arguments.

They start by saying that “individuals have a moral duty to rescue.”  That is, we should provide aid to folks in urgent need as long as it “involves minimal risk and burden.”  They didn’t provide a reference for this statement, so I thought I would try to see if there is a literature to support this declaration.

It turns out -according to my favorite crowd-sourced encyclopedia, Wikipedia – “a duty to rescue is a concept in tort law that arises in a number of cases, describing a circumstance in which a party can be held liable for failing to come to the rescue of another party in peril.”  In common law, however, there is no general duty to come to the rescue of another -a person cannot be held liable for doing nothing while another person is in peril.  An important exception is emergency workers, such as police firefighters and physicians.

The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that hospitals (and it associated care professionals) provide emergency care to individuals up to the point of stabilization without regard to their ability to pay for it.   Thus, the uninsured are entitled by law to receive emergency care without having to prove ahead of time that they can cover the costs of that care.  Currently (despite the calls of some at the September 12, 2011 Republican presidential primary debate), we do not let people die or deliver babies in the street if they have shown up at an ED in need of care.

Rulli et al say that “because physicians and hospitals have a duty to rescue the uninsured by providing acute and emergency care, individuals have a corresponding [moral] duty to purchase insurance to cover the costs of care.”  The moral duty to purchase insurance arises because of a duty on the part of potential “rescuees” to reduce the burden their rescue places on the rescuers.  In fact, some states, like New Hampshire, have resorted to billing hikers for the cost of their rescue.  Hospitals bill people who receive emergency care but don’t have insurance.  The problem is that many cannot or will not pay those bills.  That results in a financial hardship for the hospitals that is then passed on, via higher charges, to insurers, and finally on to us in the form of higher premiums.  Now, I am not an ethicist so I can’t speak to “moral duty,” but I must that it seems only fair that everyone ought to be required to have health insurance so that I don’t have to pay higher health insurance premiums because some people cannot or will not buy health insurance.

The authors point out that there are three conditions that must be satisfied in order for potential rescuees to be required to take rescue precautions, in this case, to buy health insurance.  These are:

  1. The chance of needing to be rescued is high
  2. The burdens associated with rescue are substantial
  3. The costs and burdens of the precautions are not excessive

They go on to make a case that each of these conditions are present in the case of emergency care:

  1. Everyone, even young people who believe they are invulnerable, is at risk for requiring unplanned emergency medical care – whether because of an accident or as a result of inherited or acquired disease.   In fact, almost 24% of 18-29 year olds received ER care during the year according to a issue brief published by The Commonwealth Fund.
  2. Emergency and acute inpatient care is expensive.  Most people cannot afford to pay the full cost of receiving those types of services.  Hadley and Miller estimated that uncompensated care totaled $56 billion in 2008 (Health Affairs 27(5) 2008.
  3. Under the provisions of the Affordable Care Act, subsidies will be available to help people who cannot afford the cost of health insurance.  For those who can afford it, but choose not to purchase it, the costs and burdens of being required take the rescue precaution of buying insurance should not be deemed to be excessive.

The paper makes the point that because there is a professional and legal duty to provide emergency care, it does not matter if a person declines to buy insurance because they say they will “waive their right to healthcare” if something bad happens to them.  The reality is that if such a person presents to an emergency department acutely ill or injured, the ED staff must treat them.

The authors close by saying the moral duty to buy insurance only requires individuals to buy enough coverage to cover the costs of acute and emergency care.  They are not morally obligated to buy a health plan that covers preventive services or other types of elective care.

I like this paper because, as I stated earlier, it synchs with my idea of fairness.  If you can’t stomach the egalitarian concept of insurance (we all throw some money into the pool to cover each other when one of us gets sick), then perhaps you can go with the more libertarian concept that individuals have, as the authors conclude, “a duty to mitigate the burdens of rescue they pose on others.”  Either way, we get to universal coverage and that in my opinion is a very good thing.

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