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josie's avatar

Shouldn't recipients of health care benefits be subjected to the same moral scrutiny as the payers?

Asked by josie (30931points) July 18th, 2017

The current “health care” debate (it isn’t health care, it’s sick care, but never mind) centers around the question as to whether or not well people should be forced pay more than they need to into a pool in order to care for people who are not well but cannot or, in some cases, will not pay for themselves.

The moral justification for this is that somebody must pay for the sick, so why not the well?

On the other hand, there does not seem to be the same moral pressure upon the recipients of the benefits of forced contribution to the pool.

I do not hear much talk about forcing fat people to exercise and eat fewer fries. I do not hear much talk about forcing people to quit smoking and practice safe sex. I do not hear much talk about forcing people to be generally thoughtful about health issues, instead of impulsive.

I AM NOT talking about conditions that people do not control. The most conservative folks I know are willing to help those afflicted in a fashion that does not involve choice.

But where choice is an issue, why not the same moral pressure?

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28 Answers

Mariah's avatar

OK, I’ll bite.

In countries that have implemented single-payer, the system is often funded in part by an increase in taxes on unhealthy items such as alcohol, cigarettes, and junk food. This helps reduce the country’s healthcare costs in addition to accruing revenue for the system.

However, when you get talking about “forcing” people to exercise and eat better, I wonder how you’re imagining we could ever enforce such a system? How would one determine which health issues were caused by behavior and which ones weren’t? How would anyone prove they weren’t eating fries? I also think you’d be hard-pressed to find anyone who’d be in favor of this kind of restriction of freedom.

“The moral justification for this is that somebody must pay for the sick, so why not the well?” This doesn’t really feel like an honest explanation of insurance. The purpose is to spread costs of the few over the many such that individuals are paying a manageable amount and everybody can get care as they need it. You’ll benefit someday too. Everyone dies of something.

josie's avatar

That is a good response. But respectfully, it sort of misses a point
It isn’t insurance when people have to join the same pool as high risk takers, and when the people at incresed risk do not pay for the increased risk.

If I build a house in a hurricaine or flood zone, my premiums will and should be higher than my friends who live inland or on high ground.

There is no health insurance anymore. There are are only third party payers who can only pay for the sick as long as the well agree to pay a sick level premium.

Insurance companies understand insurance.

They do not understand being payers.

Anyway, I am only talking about those people who, as far as we know, are increasing their risk as an act of choice.

As I said before, I think most people are supportive of the sick who are true victims of fate. I infer you may be one of those. In which case I would welcome you into my pool.
Such folks are a small group in the overall pool.

But, speaking only for myself, if you are a sedentary, over eating, smoking, drinking slob with a weight problem and self induced type 2 diabetes, I would rather take care of your bad habits, or be in another pool

Mariah's avatar

Again you run into the problem of proving that somebody caused their own illness. BMI is known to be a very flawed measure that often results in muscular people being labelled overweight. I’d have a problem with using it as a basis for discrimination. Proving that someone is sedentary or eats poorly seems like a difficult task without following them around all day.

Smokers already have to pay more for insurance under the ACA.

I think those of us who are sick due to bad luck are more common than you think.

I would be fine with a system that taxes unhealthy items as mentioned in my first post.

funkdaddy's avatar

All insurance is spreading the risk wide enough for the policy makers to come out ahead. That’s the entire business of insurance. Any insurance. Take in more than you pay out by only paying a small portion of your policy holders.

The rest is just ways to outsmart whatever system you’re using and deciding how much risk you’re willing to take. How that’s done is almost always regulated at this point because insurers are backed by the government.

So having a government backed health insurance market, with one pool, should leverage the fact that insurers can get a huge, predictable market, with zero advertising costs to drive costs down. It should be like friggen Costco for insurance. Insurers should be clamoring to get approved to offer their policies to a huge market where only cost and quality of care matter.

It’s not that way because we can’t agree to just do it one way, so we have a busted hybrid system with pools all over the place and those who end up in the federal pool are those who can’t find insurance elsewhere. The insurers know it’s a disadvantaged pool and set prices accordingly. Most people think they aren’t paying for this pool, because they’re still in their corporate plan where prices really are negotiated fairly based on a varied population.

But here’s the kicker, you’ve always been paying for the disadvantaged pool, but their care has come from clinics and ERs rather than proper preventative care with a doctor they know and the possibility of education. People can’t see past this year’s premiums, so we’ll keep paying ER prices for the majority of people who use those facilities and aren’t able to pay their bill. (this is more than half in many ERs) You’re already subsidizing health care, but it’s pretty close to the worst policy imaginable for those who have to use it.

Why not make that better? Because no one wants to expose that you’re already paying. There’s no way to justify letting people die by denying care, and that’s the only other option. Right now insurers (as a business) don’t have to mess with that population at all, except through the marketplace, so of course they don’t want to change. The hospitals can’t run an ER, or in some cases a labor and delivery department, without the federal money, so they don’t want to call attention to it. And meanwhile we argue about whether or not people deserve real health care, because we don’t want to pay for it.

You’re already paying for it all, every time you go to an ER, every time you pay a doctor’s bill, every time you pay taxes. The prices have all the people who can’t pay figured in. Wouldn’t it be better to instead supply real health care with that money?

And then, if you want to have doctors prescribe exercise or leafy greens right along with pills and surgery, I’m all for it. Teach people how their body works and how to make it better to see if the costs can go down for everyone. Great.

But we have to get past this idea that this year’s bottom line is the only one that matters in health care.

Espiritus_Corvus's avatar

What Mariah describes in her first paragraph is end-user taxes. On the night of 31st October, 1982, I took a flight out of Kennedy to Stockholm. While in Kennedy, I bought a pack of Marlboros for $1.50 and priced a a fifth (75cl) bottle of premium Absolut Vodka, a Swedish product, at $18.00. These prices were airport prices, a pack of Marlboros anywhere else in NYC at the time was 75cents.

After I landed at Arlanda Stockholm the next morning on 1st November, I dropped by a state liquor store and priced Marlboros at the equivalent of $10 per pack and the domestic brand at $7. The same bottle of premium Absolut was the equivalent of $66 and a half liter can of the domestic pilsner, something similar to a 16 oz. Budweiser wa $11. I wondered why.

The answer was that the majority of hospital beds were taken up by people of the aging WWII generation with lung and liver disease due to tobacco and alcohol products and the voters decided that, if you are going to use these products, it is only right that you should pay more for your future medical care than people who don’t use those products. I certainly couldn’t argue with that.

In the grocery stores products were tagged according to whether or not they contained high amounts of fat, sugar, gluten (remember, this was 1982!) and salt. Price tags were different colors according to the contents found in the product. Salt free products were had yellow price tags and sugar free products had red price tags. The color coding was uniform nationwide.

This was an enormous help to diabetics, cardiac patients, patients with high cholesterol levels and allergies to gluten. I thought it rather nice that there weren’t any special sections for these products. Soup, pasta, pastries could all be found in their special sections along with the whole products. There was no need to search lite or sugar free products out.

The Lite and sugar free, fat free, low salt products were even kept arificially cheaper than whole products because it was recognized that statistically people with these maladies that required them to curb these substances missed more work that others, and had shorter working lives. So, there was even a strong incentive for the rest of us to eat more healthfully. This is the precise opposite from the States where the poorer one is, the higher the carbohydrate and fat their intake is at the cost of protein, because carbs and low quality fatty foods are cheaper.

We had State TV, comprising two channels in Sweden. Unlike America since the mid 70s during the advent of 24 hour cable programming, Swedish TV went off the air at midnight. The only TV commercials were PSAs, mostly having to do with healthy living, proper diets and exercise. These commercials were not inserted into the middle of programs like they did in the States, they were shown in one approx. 10 minute block between the end of one show and the beginning of the next. No interrupted programming. The TV fare provided was much like the quality of what you see in the States on PBS, with Swedish subtitled series productions from the UK, Norway, Finland, Denmark, Germany, France, Italy and, of course, Sweden.

There was very little American programming due to the prevalence of violence gratuitously inserted into shows from the US. I remember we got Dallas one year after each season was broadcast in the US. It was very popular.

A few years later, we got CNN and then the Stars entertainment channel out of the UK. But the two State channels remained the same and remained quite popular.

The important thing was that the people of Sweden were constantly given the data they needed to keep themselves healthy and keep their national healthcare costs down. Preventive medicine was huge there and even shopping to stay healthy was cheaper and made easier. Tobacco and alcohol in amounts beyond special occasions were beyond the budgets of most rational Swedes.

If you wanted to get shitfaced and party like it was the end of the world, you simply took a ferry on a round trip to nowhere, where you could drink to your heart’s content at tax-free prices—offshore prices. This was a favorite for wedding parties, bachelor and bachelorette parties, graduation parties and important birthdays and anniversaries.

I thought life in Sweden was much more rational and the Swedes in general were much calmer and more level headed than the people in the States. They had found rational solutions long ago to problems we are still struggling with almost 40 years later.

The fact is, josie, you don’t have to hold a gun to people’s heads to successfully get them to live right. All you do is, with a little patience, give the the proper information and the proper incentives and they will eventually fall in line.

I really have a hard time understanding that. We really could have the best of both worlds.

Darth_Algar's avatar

“I do not hear much talk about forcing fat people to exercise and eat fewer fries. I do not hear much talk about forcing people to quit smoking and practice safe sex. I do not hear much talk about forcing people to be generally thoughtful about health issues, instead of impulsive.”

Yeah, sounds swell until you think about the billions of additional dollars and bureaucracy (don’t conservatives typically hate those things?) that would cost.

Espiritus_Corvus's avatar

@Darth_Algar You save enormously on the other end by lower instances of obesity-related diseases such as early Type II diabetes, cardiac disease, peripheral vascular disease, neuralgia, chronic back problems and surgeries—and a plethora of other maladies.

Remember, obesity shortens one’s working life and therefore impairs one’s ability to pay taxes, but these people still need to be attended to, given medication, hospitalized and operated on when they go into crisis. And the crises are chronic as is the disease of obesity.

Who do you think pays for that?

Zaku's avatar

I do not hear much talk about forcing fat people to exercise and eat fewer fries. I do not hear much talk about forcing people to quit smoking and practice safe sex. I do not hear much talk about forcing people to be generally thoughtful about health issues, instead of impulsive.
Probably because that would be awful even if (or especially if) someone actually thought there were any way to do that.

It isn’t insurance when people have to join the same pool as high risk takers, and when the people at incresed risk do not pay for the increased risk.
– I think that it’s good that it isn’t insurance! Insurance is a nasty business, and a leech on society that we have far too much of.

But to address the sentiment I think I see behind your question, I see your point, and think it is very money-oriented and seems much less important to me than making sure we correct our currently-atrocious system where many people end up being screwed up & over in so many ways by medical and insurance costs. Especially when in many cases, the costs are ridiculously high.

To me, I think first priority should be to make healthcare affordably available to everyone, when it isn’t actually unreasonable to do so. Treating wounds and injuries and sicknesses and providing medicine that make huge differences for people and don’t really need to cost much? That should not be a for-profit industry buried under two other for-profit industries (i.e. for-profit hospitals, health insurance, medical malpractice lawsuits)! If anyone should justly pay for the reorganization, by rights it should be those industries that have been raking in the profits for decades and causing way too much unjust suffering.

I think that once actual costs can be fairly assessed without those for-profit industries setting the prices way too high, then there should be some bars to how much society invests on people without requiring substantial payment. Some of the medical treatments we have now really are expensive and they probably should have some costs and restrictions around when we choose to use those.

As for whether healthy people should be made to pay for unhealthy people, I think there is plenty of room for a reinvented system to not have that be a burden. I think the weight of the issue is greatest when the economy has people worried about not being able to make ends meet, and being required to work hard (often at jobs they don’t enjoy) to struggle to have enough. That should also be turned around. I think people should be able to afford to live without such worries and get health care, and I think it’s entirely possible, and eventually will be necessary, and the sooner we reinvent these systems in ways that work for people, the less suffering three will be.

Darth_Algar's avatar

@Espiritus_Corvus “You save enormously…”

Yeah, I don’t really buy that.

Espiritus_Corvus's avatar

You don’t buy it because you live in a system that doesn’t buy it, a system where it is every man for himself and fuck everybody else. The county you live in is packed with cynical, self-defeating people. Somewhere along the way, Americans decided to lose hope, to stop looking for viable answers to their problems outside of their own environment. They became parochial.

Part of this is arrogance, part of it is sheer intellectual laziness and contempt for new ideas because an investment in cynicism incurs the idea that all new ideas are useless and are doomed to failure. A cynic is invested in losing. (In this, there is a huge difference between skepticism and cynicism) Cynicism arrests progress and is a self-fulfilling prophecy. It is also a choice.

I suggest you travel either through a library or throughout the real world, examine other systems, and other societies. You might become less cynical as you see countries that have long ago solved a lot of the problems we are discussing here on this thread. And you will find that most people outside of the States aren’t as hopeless in their minds and fucked up as you seem to think. Even in a shithole like Haiti, people are more hopeful toward the future, because they know to go the other way will surely guarantee that there will be no change. So they bravely struggle on.

Most people respond to common sense, because common sense is rewarded behaviour. Americans don’t seem to know what common sense is anymore.

Pandora's avatar

What makes you so sure that the healthy person won’t get sick in there lifetime and that they won’t get cancer or into some accident? Healthy people suffer from heart attacks all the time. Okay, so not exactly healthy, but you hear of athletes that seemed in prime health until they weren’t. Some people eat like crap and smoke or drink, and those suckers are never ill, because of genetics. I know a few old people in the south who fit that description and are quite old but hanging in there. Old people in general have a need for more health care. Do you cut them off because they are getting old? If a woman has a high risk pregnancy. Do you cut her off ? I mean, where does she get off trying to have a baby that will possibly raise health care rates for everyone? (I’m being sarcastic there.)

Just pointing out that life isn’t perfect. It’s messy and as a society that claims to be humane, we should all pitch in to help our brothers and sisters. Generally. I’ve been pretty healthy most of my adult life. I was a sick kid. Did nothing then to be sick. Just was unlucky. But if it wasn’t for free and low rate medical care in NYC when I was growing up, I would be dead today.

Also, do you want the government to keep track of everything you do? How often do you drink? Do you speed when driving? Are you willing to go in for random blood draws to see if you are doing drugs? Should you be penalized for a genetic trait in your family? Are you involved in any risky behavior? Skydiving, car racing, horseback riding, jet skying, scuba diving, mountain climbing, log climbing? Do you go to the gym regularly? Would you like your gym to have to keep track of how many hours you work out? Are you willing to go in for a physical every 6 months mandatory to keep track or your health? Should the government start a special tax on donuts? There already are taxes on cigarettes. They keep raising the taxes on them because they say it’s to help with the cost of lung cancer caused by cigarettes, yet I wonder where is the money really going.

Espiritus_Corvus's avatar

So, what’s your point, pandora? People age and get sick? Some people can abuse substances all their lives and still live to be ninety? Gee, who knew?

Statistically—history bears this out—people who take care of themselves don’t get sick as often as those who don’t take care of themselves, they have longer, happier, more productive working lives and pay into the system longer. Nobody wants to get sick. And here’s statistic for you—people who have a more positive view of the future want to live longer, they take better care of themselves.

People who don’t have a positive view of the future don’t take as good care of themselves, because often they stop giving a shit—at extraordinarily young ages. There is something really wrong with that. There are many young people now who have surrendered to pessimism so deeply that they are basically just waiting to die, they goddamn near envy the dead.

My feeling is that if they were given the tools to make a good living, such as tax payer paid college tuition—where they don’t come out of University in hundreds of thousands of dollars in debt, and tax payer paid healthcare, they may not feel so hopeless, have a more positive view into the future, and they might even want to contribute to the common weal to do the same for the next generation. That’s what I see going on in countries in Europe that have systems that invest into their own people with their people’s tax money.

But, yeah, a few are going to get sick. Shit happens. So what?

canidmajor's avatar

“I do not hear much talk about forcing fat people to exercise and eat fewer fries. I do not hear much talk about forcing people to quit smoking and practice safe sex. I do not hear much talk about forcing people to be generally thoughtful about health issues, instead of impulsive”
Maybe you don’t hear much of this talk because you are one of a (fortunately) small percentage of people who want to force others to do what you want them to do.

Personally, I hear a lot of talk about improving one’s health, suggestions that point to better eating, better moving, better health practices in general.

I could enumerate the ways in which poverty eating is specifically responsible for obesity (and consequently ill health) in the economically disadvantaged, how nicotine actually suppresses appetite, how the physical fatigue of working many jobs prevents constructive exercise, but you have no interest in that, @josie, you’d rather force them to your rather harsh (and unrealistic) will.

The idea of forcing other people to do what I want them to do is anathema to me.

janbb's avatar

Also, @josie , Medicare and many private health insurance policies do pay for well baby check-ups, annual check-ups, mammograms and other preventative care measures. There is an emphasis on health, just not in a coercive way. I think your entire premise is flawed. And self-contradictory – you don’t want any intrusion into your health records and yet you seem to imply that you would be in favor of coercive health prevention measures. You can’t have it both ways.

chyna's avatar

My insurance company gives discounts for not smoking, low cholesterol and annual visits to the doctor for mammograms and other preventative screenings.
I have high cholesterol due to family history, not due to my weight or how I eat. Is it fair that I eat well, watch my weight, but have to suffer the same consequences as those that don’t? Meh, it’s life.

Zaku's avatar

Punishing people for not taking care of themselves seems to me like an atrocious and foolish idea. It’s not like people usually logically weigh the pros and cons and decide to neglect themselves, so taking some of their money (or shaming them) will cause them to change their ways. Some might, but generally self-neglect is caused by personal issues that would tend to be exacerbated by more stress.

To address the issue of people neglecting themselves, assigning them more education, counseling, and opportunities to love their lives would seem the more logical approach, to me.

But if the issue is resentment that “lazy slobs” are having money spent on them while money is taken from others who are having a hard enough time already, that to me is two issues, and the far more important one to me is making sure everyone isn’t having a hard time, without the fairness/jealousy argument piled on top. If the fairness issue has a reasonable factual basis, then let’s reward the people who take care of themselves (though it seems to me the system and the universe already richly reward that), rather than further abuse those of us who are struggling.

Darth_Algar's avatar


Goddamn, did you even read what I had quoted before deciding to respond to me initially? I’d suggest that in your goal to be a pompous ass you at least make sure you’re railing against an argument that’s actually being made.

janbb's avatar

@Zaku Beautifully said!

Smashley's avatar

You are describing an American style authoritarian dictatorship, aren’t you?

I mean, dividing people into in groups and out groups, worthy of different access to health care and different financial penalties, based solely on their personal cost to a medical system that has never been interested in keeping them healthy.. yikes. I know you can call them slobs or losers or whatever, but you’re taking about a massive amount of people with no universal commonalities except how much they cost. Oh? You only mean to punish the people who’s own fault it is? Well, lets write up that legislation! I’m sure that it will take the entirety of human experience into account, employing a clarity of causality derived from perfect science that will never be shaken by new data, with no innocents destroyed in the process.

Now that we have that legal mechanism, we need enforcement, and surveillance and data collection to make sure that only the at-fault sickos are punished. Don’t worry that you need to have your blood checked every month to prove you aren’t a vile leech of a “faultie”, our other techniques, like tracking your debit card usage to create an individualized fault profile, will be painless and invisible :) We are the government, we will never make a mistake! Oh, we are making mistakes? At least it’s only lives at stake, not something important.

Look. All sarcasm aside, you are ignoring how health insurance systems protect societies and how healthcare is different than other services you can buy. You’ve also failed to examine how crazy and immoral it would be to try to punish what is currently viewed as bad personal decision making. As others have pointed out, it is much simpler and morally defensible to tax products that harm society, or incentivize behaviors that benefit it.

Espiritus_Corvus's avatar


Yes, I did. You said that you didn’t buy the fact that a country saves enormously on the other end by educating people, making it easier and cheaper to buy the right foods and to practice preventive medicine.

And I said you are wrong and also why I think you and many others like you take that position.

Darth_Algar's avatar


You said nothing about educating people. You replied to my comment on @josie‘s noting of forcing people to exercise, eat healthier, etc. Maybe to you “force” and “education” are interchangeable, but most other folks can understand the difference. You’re reading what you want into my statements and trying to take me to task over something I’ve not argued.

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