I have a fairly healthy lifestyle. I don't smoke, do drugs, ingest caffeine or consume much highly processed, marginally nutritional food. I workout regularly, get good sleep and otherwise am conscious about maintaining a good diet and healthy lifestyle. My annual physicals affirm my choices: cholesterol, blood pressure and all other indicators are in the solid healthy range.
My health is not an accident, it's a conscious lifestyle decision. And I'm not alone. There are more than a few uber-healthy folks in my neighborhood and quite a few others spread across this land. Sadly though, we are a minority - the balance being at-risk for smoking and weight-related diseases such as hypertension, diabetes, heart disease and cancer. Smoking alone kills 1 in 5 adult males.
Fine, everybody makes their choices. What is not fine however is when the healthy are forced to subsidize the costs of the those who repeatedly make high risk / cost lifestyle decisions. Yet this has been the model since the 1930s.
Whole Greater Than Sum of Parts versus Weak Link
The group model is predicated on the belief the aggregate or collective is much stronger than its individual constituents - a tribe or team is more powerful and therefore has a higher survival / sustainability coefficient than the individual. Those more fortunate, either by design or inheritance, should help the less fortunate in order to maintain the collective tribal bar and keep that subset of the species moving forward. It's a good theory and quite arguably, one that has hastened evolution.
Tribes establish rules in order to maintain a group performance standard: be it defending its borders, competing for trade, mining its internal resources or acquiring external ones. Mechanisms within the tribe reward good decision-making and penalize bad. When elements counter to the tribe's charter arise, they are suppressed or eliminated rendering a more cohesive whole. This is pretty much how society has advanced to its modern state. Other models are possible but not likely given our evolutionary stage.
Modern health insurance was originally conceived to reduce competition among hospitals offering pre-paid plans. Odd, as anti-trust laws generally prevent this kind of reduction. Nevertheless the concept took hold and initially benefited both consumer and provider. But more importantly, it benefited society. Lifespan increased, those marginalized by poor health became more productive, financial destitution from catastrophic illness was reduced and so on. We became a stronger tribe as resources and energies were distributed more evenly and more strategically among the afflicted. Group health insurance seemed like a pretty good bang for the buck in our march forward.
Such a shared risk / benefit model like health insurance generally works quite well in mitigating anomaly induced stress on a social unit. However as anomalies increase and the cost to deal with the anomalies increases, the system can become over-stressed, in fact burdened to the point where evolution is jepordized.
There may be some formula that describes the exact breakpoint where the shared risk / benefit model collapses but in the case of heath insurance we seem to have reached it as more is being extracted from the system than can be supplied to maintain it. Of course one of the symptoms of the stress and breakdown of the model is social unease and agitation to restore balance. And this is precisely where we find ourselves today.
Divide and Conquer
Part of the solution may be found in recent precedent. When financial systems began unraveling in the 3rd quarter of 2008, 'toxic assets', liabilities actually, were identified and separated out of the portfolio. The general thinking was this could mitigate contamination and guilty-by-association effects. Plus its easier to deal with like kinds. The segregated liabilities could be managed more effectively and net loss minimized. This is not a new strategy as we have been using it both individually and collectively since we started walking up-right. From the pile of clutter on the corner of desk to garage sales, the strategy of divide and conquer is ubiquitous.
Of course you know where this is going. Why not separate out the 'liabilities' and deal with them as a separate group? If you choose to repeatedly indulge in health compromising behaviors, you get your own group. Smoke? Obese? Bad diet? Repeat seatbelt violations? Not a problem. But you're in the wrong line. What you want is the 'At Risk' line. Yes I know, it's more expensive as not only will you be mandated by law to purchase insurance but your premium costs will be based on YOUR 'At Risk' group only. Ouch I know.
Oh, and you folks whose annual physical exams and bloodwork demonstrate you are choosing health-promoting decisions? Congrats, there is no line. However, if you feel you need to underwrite your fears, your premium cost will be derived from the 'Healthy' group. Yeah a bargain ey? The choice is yours.
Line Dance
Line Dance
It is very simple to draw the line. In fact the line has been drawn and corroborated by plenty already including the AMA the CDC and others with a vested interest in our collective health. Cholesterol above 200? Get in line. What, borderline you protest? No dice, you are at risk. When your levels have dropped for 6 months you can reapply to the Healthy group...Next. BMI above 30? Get in line...Next? Blood pressure above 140/90? Get in line...
The beauty of such a system is twofold. First, the healthy are not penalized. Under the current model the benefit from my good decisions is being spent on the loss from your bad decisions. Second, the At-Risk group is being penalized by significantly higher costs which impacts their lifestyle. Add in social stigma, choice reduction and other behavior modifying forces and the upshot is there is now more incentive to make healthy choices. Behavior modification is easier to achieve with a more heterogeneous group especially when combined with assist mechanisms like Patient Centered Medical Home.
The ultimate question however is: does this advance us as a tribe? Are we collectively brighter, stronger and more capable? Does segregation of risk ultimately render a higher average standard of living? Does division result in a higher GNP, GNH (happiness), GNC (creativity) ? Does it save money? Is it a more effective apparatus for increasing collective health? Does it ameliorate the burden on those most capable to advance society? I believe the answer is YES.
