Vulnerable Invincibles
posted by Frank Pasquale
We had a good discussion about “rationally” choosing to be uninsured here about two years ago. Here’s an interesting NYT article on how one subset of the uninsured–twenty-somethings known as the “young invincibles”–are deciding on whether to obtain insurance:
[Some] people in their 20s shun insurance . . . because their age makes them feel invulnerable or because expensive policies are out of reach. . . . [When sick,] they borrow leftover prescription drugs from friends, attempt to self-diagnose ailments online, stretch their diabetes and asthma medicines for as long as possible and set their own broken bones. When emergencies strike, they rarely can afford the bills that follow.
Internet diagnoses, self-medicating and trading prescriptions, of course, come with potentially dangerous side effects. Dr. Barbie Gatton, who has worked in emergency rooms throughout the city since 2002, said she often sees young people who have taken the wrong antibiotics borrowed from friends.
“We see people with urinary tract infections taking meds better suited for ear infections or pneumonia — the problem is, they haven’t really treated their illness, and they’re breeding resistance,” she explained. “Or they take pain medicine that masks the symptoms. And this allows the underlying problem to get worse and worse.”
Mary Crossley’s excellent article on Discrimination against the Unhealthy in Health Insurance provides good perspective on some of the “invincibles’” despair at getting insurance or paying their bills. She “describes a growing body of research showing that unhealthy people can be expected disproportionately to pay the price for [a consumerist model of health care], not only in dollars, but in preventable disease and disability as well.” But given the toxic rhetoric that’s already entering America’s health care debate, some wouldn’t be surprised if China gets universal health coverage before the US does.
February 18, 2009 at 1:14 pm
Posted in: Health Law
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Responses (8)
JP - February 18, 2009 at 3:39 pm
It’s unfortunate that the NY Times article is just a collection of anecdotes without much apparent point. I would be very interested in some analysis of the rationality of these uninsured invulnerables’ decision. Based on the article’s reference to 13.2 million uninsured, and monthly premiums of at least $400, they are collectively saving over $60 billion a year on insurance. I wonder how much they collectively incur in medical expenses?
However, since the article is a collection of anecdotes, I interpret it as a pretty strong argument for consumer driven healthcare:
“Mr. Aaron was one of several young adults who said living without insurance meant trying to take better care of themselves.”
Brett Bellmore - February 18, 2009 at 8:11 pm
What do you suppose is the logical difference between somebody with a very low probability of needing medical care refraining from buying insurance, and somebody with a somewhat higher probability of needing medical care buying insurance with a finite lifetime payout? In either case you’re taking a calculated risk.
Even when people take rational risks, sometimes it turns out badly. Therefore demonstrating that a decision has turned out badly for some small percentage of people making it doesn’t demonstrate that they had made irrational choices.
Frank - February 18, 2009 at 8:34 pm
To Brett and JP: Do you favor lifelong indenture for those who can’t pay when it “turns out badly”? Nondischargeable bankruptcy debt, or, say, debtor’s prison?
If not, then these individuals’ calculated risks are effectively spilling over onto the rest of us taxpayers, who will eventually be covering the services they use. The young invincible who stays healthy is effectively evading a risk pool that helps the sick and poor. The one who gets sick faces all the problems noted in the article.
A.J. Sutter - February 18, 2009 at 9:10 pm
Um, admittedly this is not the usual type of comment I make on this blog, but as for that $60 billion: doesn’t one have to internalize all the other costs involved? Such as lost time at work, infections of other people, consequences of antiobiotic resistance (to the “invincibles” and those around them), etc.? And what are they doing with the money: saving it? Are they spending it in the general economy, where it can be used to create jobs? Or are they simply not going into hock by that amount?
BTW, as for “living without insurance meant trying to take better care of themselves”: I live in a country with a near-universal health care system (“near” universal, effectively because of recent American-inspired changes to labor laws). In the US I was uninsurable, due to being self-employed with a very mild case of asthma. Here, even as an alien, I pay less than $50 per month for everything, with incredibly small co-pays, and without regard to pre-existing conditions. But despite living under this cloud of socialism, people in this country have the longest average life expectancy anywhere.
JD - February 18, 2009 at 10:17 pm
“Discrimination against the Unhealthy in Health Insurance”–what a stupid title. The point of “insurance” is to “insure” BEFORE the bad thing happens. Once you’re already unhealthy, you’re not “insuring,” anymore, it’s like buying fire insurance while your house is burning down. The insurance model may be inappropriate for a variety of reasons, but as long as we have it, it’s absurd to talk about “discrimination against the unhealthy.”
JP - February 18, 2009 at 10:43 pm
Frank: No.
Also, I have a few responses to your comment that the “young invincible” is evading the risk pool. First, so what? They are, by and large, low income. I’m opposed to the regressive system by which the young and poor subsidize the healthcare of their wealthier elders. Second, despite my libertarian tendencies, I readily concede that a federal (or state) social insurance scheme would be vastly preferable to our current system, if anyone can convince me that there is a way to design and implement one while avoiding the public choice problems that make our current system so bad.
A.J.: Of course one has to consider all of the costs–and the benefits. The article didn’t consider either (except for the costs of a handful of people who got sick). In my opinion, that makes it a stupid article. Also, whether they are saving, spending, or just not borrowing the money not spent on premiums, in my estimation it is almost certainly better used than enriching insurance companies or subsidizing the (relatively wealthy) elderly.
Finally, my point about consumer driven healthcare was intended to be a facetious remark about the pointlessness of the article. You can draw any conclusion from a not-so-randomly selected set of anecdotes.
Brett Bellmore - February 19, 2009 at 6:06 am
“To Brett and JP: Do you favor lifelong indenture for those who can’t pay when it “turns out badly”? Nondischargeable bankruptcy debt, or, say, debtor’s prison?”
How about making insurance with actuarially correct rates and a moderately high deductible available to people in their circumstance, instead of viewing folks with a very low probability of needing the insurance as a piggy bank to raid? So that it actually becomes rational for them to buy insurance?
One of the reasons they don’t buy insurance is that it’s a raw deal for them. It appears you like treating them that way.
Frank - February 19, 2009 at 8:45 am
There’s no way to model this as either a “raw” or “good” deal for individuals. It’s a question about what type of society we want to be. Most of the industrialized world finds the prospect of forcing the poor into a game of “health roulette” unappealing.
As Thomas Edsall noted in his book “Building Red America,” a preference for more risk in every area of life is a hallmark of some political movements in this country that have no real parallels elsewhere. The sad thing we are coming to realize is that these risks tend to spill over onto other people–the bankers who leverage to the hilt are going to get a bailout, given their political power, and the biker without a helmet or insurance who gets in an accident and becomes very disabled is likely to become a ward of the state. Deregulating banks or letting people go without insurance seems like a great idea when times are good, but times never stay good forever.
Massachusetts has pioneered a plan to at least assure that some form of affordable insurance is available to people like those featured in the article. That’s a much more humane approach than just letting people take a gamble, and then saying “game over” when they happen to lose.
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