The Moral Quandary of Self-Pay Healthcare

One of the challenges to honestly addressing healthcare reform is that the language we use is often not descriptive of the actual economic situation.  A U.S. Court of Appeals recently ruled in favor of the constitutionality of the mandate to purchase insurance.  The ruling used the term “self-insurance” to refer to people who could afford to buy insurance but choose not to. The language is wrong – self “insurance” isn’t possible.  By definition insurance is shared risk.  When something goes wrong the costs of the few are shared by the many.

What the ruling is actually talking about is self-pay – if you have something go wrong, you pay for it.  In healthcare this is a challenge because many events cost tens of thousands of dollars and often hundreds of thousands.   Most people don’t have the cash lying around to pay their medical bills if something bad happens to them.

This is the quandary facing our country – very few of the people that can afford insurance but choose to self-pay can actually afford the cost of an unexpected catastrophic medical situation.  It’s an unpleasant choice – obligate emergency departments to save a person’s life and allow the hospitals to shift the cost of care onto other people that use the hospitals, or let hospitals refuse emergency service to uninsured people who can’t show an ability to pay, and likely have them die.

At the moment, society picks up the tab – we choose to save the 24 year old who didn’t take health insurance at his job but unfortunately rolled a 4 wheeler over on himself.  But it’s a hard situation, because to a degree this means the responsible wind up subsidizing the irresponsible.

For the responsible, that burns just a little bit – they made the financial sacrifice to make sure they had insurance, and now they have to pay for the people that didn’t make the sacrifice.  But it’s a tough question.  Irresponsibility can take many forms, and frankly most people behave irresponsibly in at least one way or another.   Should that really cost a person his or her life?  But this is part of the conversation we need to have, and why the accuracy of the language is important – it is self-paying, not self-insuring.  If we let people go without insurance, let them self-pay, what should we let happen to them if they can’t pay for their care?   How far should we go in protecting people from their own irresponsibility?

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