• Rulli, Emanuel, Wendler: Individuals have a moral duty to buy health insurance

    In JAMA, Tina Rulli, Ezekiel Emanuel, and David Wendler argue that individuals have a moral duty to buy health insurance. Their argument hangs on the premise that physicians have a moral duty to rescue, e.g., to provide emergency treatment. This duty is written into statute: the Emergency Medical Treatment and Active Labor Act (EMTALA). In turn, the authors argue, individuals have a corresponding duty to reduce the burdens of rescue. The authors impress upon the reader the magnitude of these burdens with this paragraph:

    Many individuals forgo health insurance assuming they will not need medical care. However, everyone is at substantial risk of needing medical care—even young adults. Fifteen percent of 18- to 29-year-olds have asthma, arthritis, cancer, diabetes, heart disease, or hypertension. More than half of these individuals are overweight or obese. In 2007, there were 2.6 million live births among women aged 18 to 29 years. One-fourth of all human immunodeficiency virus/AIDS diagnoses occurred in 20- to 29-year-olds. Almost 24% of 18- to 29-year-olds received treatment in an emergency department during the past year.

    The conditions mentioned can all lead to the need for emergency care, triggering the EMTALA mandate. All but the first sentence of the quoted paragraph reference this Commonwealth Fund issue brief. It’s ungaged, as is the JAMA piece. So, you can read and judge the merits of the details yourself.

    Can I trust that you’ve read Bill Gardner’s thoughts about the Rulli et al. paper, as well as his follow up? You really should. It’s your moral duty. Or maybe not. You decide.


    • 1. Maybe so but one could also say that capable people with above average intelligence (let’s say people who attended at least one year of college) have a moral obligation to have a deductible of $50,000 or higher. For reasons outlined here.

      2. Why in so many minds is it so superior to prepay for healthcare than to pay after receipt or care? One could say that people have a moral obligation to pay their medical bills. Also do a guy making minimum wage.

      3. One could say people also have a moral obligation to not consume more care that the insurer is paying for than they would if they paid directly.

      4. One could say people also have a moral obligation to shop for price even if an insurer will pay.

      • Oh an BTW Governments have a moral obligation to not put road blocks in the way of providers willing to provide care. I know some Doctors who practiced medicine in other countries who are not allowed to practice here. Why? Also, mostly anyone with above average intelligence given a few hours training should be allowed to give shots. Etc.

    • This is an interesting topic that sparks a number of thoughts for me. I’m interested in other’s feedback.

      The Rulli et al conclude:
      “Although the Supreme Court will decide the constitutionality of the ACA insurance mandate, this analysis suggests that requiring individuals to buy health insurance is consistent with respect for individual liberty because individuals have a duty to mitigate the burdens of rescue they pose on others.”

      It’s fine to make this argument, but I think the authors have to be willing to accept the logical conclusions of the position, and I’m not sure they would. In “mitigating the burdens of rescue”, shouldn’t that also include taking the necessary steps to avoid rescue in the first place? The authors cite obesity and complications (e.g., cardiovascular, endocrine) as evidence of the other side of the moral burden. To fully execute the moral responsibility that the authors cite, individuals should also eat healthfully and exercise regularly to avoid rescue care in the first place. What logic do the authors use to draw the line that gym memberships and broccoli consumption are beyond the pale? This is the limiting principle the dissenting SCOTUS judges could not find in the Government’s argument.

      Doctors don’t have the ability to pick and choose when their moral obligation to provide care starts (i.e., not provide care to individuals who need emergent care because they haven’t taken care of themselves or have put themselves in a risky situation and lost), so individuals also should not have the ability to pick and choose their risk behaviors and insurance. But this is not what the authors conclude.

      In contrast, I think the logical conclusion of the author’s argument, if purchasing insurance is the remedy to mitigate the medical profession’s responsibility, is to support risk-weighting of insurance products. That is, smokers, the obese, sky divers, coal miners, food critics, etc. must be charged higher premiums based on their risk profiles, for the same catastrophic-only coverage. While risk-averse healthy people could get the catastrophic only coverage that the authors say is the universal coverage at a lower premium, other groups should have to purchase insurance at such a level that is commensurate with their health status, career and risk appetite.

    • The piece got me thinking, and the missed angle is the notion not that obtaining coverage is a moral responsibility (it is), but the “2012 premise” that but for these 5-10 million individuals, the cost shift would not exist. If they simply paid their fair share, the honest working souls who pay their bills would experience a significant drop in their premiums and all would be well.

      No. Its about preparing the populace for the day ESI begins to whither (by design) and it becomes the responsibility of all to obtain coverage. The firewall between the 25-45 yo’s in the individual/SG vs self-insured market is strong and I see no daylight. It still us vs them so to speak. The groundwork for introducing a moral case for purchasing insurance will be novel for those individuals coddled by HR dept’s x decades–and they begin to weigh cash vs policy.

      Additionally, Paul’s conclusions on the moral responsibility of physicians is priceless and a worthy alternate perspective. A correct one I might add.


    • My mistake. Bill G. from referenced post at SNUR, not Paul