Insurance Denial and Self-Influenced Health Problems

Table of Contents

Introduction………………………………………………………Rose Alexander, Heather Brook

Background of Health Insurance Coverage……………………………………….Rose Alexander

Positive View of Health Insurance Denial……………………………Ashley Rivard, Ilia Mondoy

Negative View of Health Insurance Denial…………………………………………..Clint Ludlow

Solutions for Insurance Coverage of Self-Influenced Health Problems……………...Mary Takagi

Relevance to the Profession of Nursing……………………………………………..Daniel Hower

Conclusion…………………………………………………………………………..Heather Brook

Editor………………………………………………………………………………..Heather Brook

Insurance Denial and Self-Influenced Health Problems

The concept of health insurance has been an integral part of our culture for many years. It can be defined by the following: “A group of persons contributing funds to a common pool, usually held by a third party. These funds are then used to pay for part or all of the costs of a defined set of health services for the members of the pool. This third party can either be a governmental social security, a public insurance fund pool, employer-sponsored pool, or a private insurance fund pool” (Akal & Harvey, 2001, p.18). As anyone who has dealt with insurance companies knows, the process is rarely as simple as it may appear at first. It depends on a very delicate balance between input of funds, medical/health care expenses, the profit the insurance company must make, and other complicating factors. The apparent disruption of this balance causes parties to fear that the system is treating them unfairly. A current fear for a growing portion of the population deals with insurance coverage of individuals who have self-influenced health problems. Insurance denial for self-influenced health problems such as smoking, obesity, heart disease, and diabetes is directly applicable to the nursing profession and society as a whole. Both positive and negative views of the issue deal with the cost of health insurance and health care, ethics of the insurance system, and individuals taking incentive for their own health.

Background of Health Insurance Coverage

Health insurance companies have different ways of dealing with the individuals of self-influenced diseases. Individuals with conditions caused by things such as smoking, obesity, drinking, or substance abuse, are likely to fall into what is known as a high risk category which normally includes people with serious or chronic illnesses, self-influenced or not. These people are put into a government program which will allow an otherwise uninsurable person to get insurance (Achman & Chollet, 2001, p. 7). Each individual state has different legislation that governs who insurance companies can deny. In Washington State, for example, “insurers must sell to everyone except the sickest 8% of the state’s market consumers. The excluded population can enroll in the state high risk pool” (Achman & Chollet, 2001, p. 7).

Given the state standards for insurance denial, it is very difficult for insurance companies to turn down anyone based on a self-induced health condition. By looking at insurance quotes from large companies, it appears that only age and smoking increase an insurance premium. Smokers have an increase of approximately 15.5% to their monthly premium, while an increase in 15 years of age results in a 63.9 % increase in premium (BlueCross BlueShield Association, 2007).

In spite of this, it must be considered that insurance companies have other methods for reducing their risk of loss due to preexisting health conditions of new clients. One way is to exclude the preexisting condition from coverage. For example, a heavy drinker suffering from a recent history of liver damage can easily get coverage, but may be denied care relating to that specific condition. Through the Health Insurance Portability and Accountability Act (HIPAA), federal law ensures that this exclusion may last no longer than 12 months (Kriedler, 2007). There is another important state law that enables insurance companies to deny claims regarding alcohol consumption. The Uniform Accident and Sickness Policy Provision Law (UPPL) allows insurers to deny treatment if any alcohol has been consumed, even if the condition being treated is not causally related to alcohol use (Barclay, 2007). This means that anyone who consumes alcohol takes the risk of being denied coverage during the time in which alcohol is in their blood.

In considering the major categories of self-influenced health problems, the associated cost increase in medical expenses is important to look at. Obesity is the most dramatic, demonstrating an average 35% increase in service expenses and a 75% increase in medication expenses. Smoking comes in second, with an average 20% increase in service costs and a 25% increase in medication. Drinking problems and simply being overweight pose more negligible increases in cost (Sturm, 2002, p. 249). These cost increases constitute the basis for the controversy over whether or not it is ethical to insure or deny the individuals who induce their own health problems.

Positive View of Health Insurance Denial

The American society places a high value on human life, and generally wants and expects quality medical care. Health insurance is one of the top concerns of the American people today. There have been many different attempts to curb spending. In the 1990’s, insurance companies restructured their payment schedules, and attempted to bring business savvy to the health industry in hopes that competition for business would keep the price of healthcare manageable (Chitty, 2005, p. 414). This leaves the country asking a significant question: “Is health care a privilege or a right?” With the costs for health insurance on the rise, it is important to look at the diseases that are avoidable and are costing Americans trillions of dollars a year. The American people pay a variable amount of money to cover themselves for the unseen health issues they may encounter. While it seems that health insurance should assist in paying for health conditions to which we have no control, what about diseases caused by the person? Should someone who purposefully engages in acts that are known to cause bodily harm, increasing health issues and decreasing life span, be covered the same as another who does not? Cigarette smoking, excessive alcohol consumption, unhealthy diet and lack of exercise are all contributors to diseases that could easily be avoided. Cardiovascular disease, obesity, and type II diabetes all affect Americans in the pocketbook and in personal well being each year. In order to have our patients truly embrace autonomy and take their health in their own hands, insurance should not have to pay for self-influenced diseases.

In 1980, the United States spent 8.7% of its gross domestic product (the value of all goods and services produced per nation) on health care (Edelman, 2006, p. 62). In 2000, health care expenditures accounted for 13.2%, $1.3 trillion of the gross domestic product (Wexler, 2003, p. 79). According to Edelman (2006), “The United States spends far more on health care than any other industrialized country” (p. 61). It is easy to say that the government or employers pay for health insurance, but the bottom line is that we the American people pay for health insurance. With our tax dollars, our consumer dollars, or our time at work, we all pay for health insurance. In 2002, private insurance paid for 35% of our health care costs, while Medicare, Medicaid and SCHIP accounted for 33%. Out of pocket expenses only paid for 14% of the total health care costs (Edelman, 2006, p. 63). With such a small percentage coming from personal funds, it is difficult for the client to feel the rising crunch of health premiums. The problem with our current health insurance system is that there is no incentive to worry about taking care of one’s own health because any consequences to a person’s unhealthy lifestyle are not followed by fiscal accountability. Having insurance companies and the governmental health insurance agencies pay for health conditions related to lifestyle habits fosters a dependence on the insurance system and does not allow consumers to truly become motivated to choose a healthier lifestyle.

According to Wexler (2003), Cardiovascular disease is the primary cause of death, which killed almost 168,000 Americans in 1999 (p. 55). This disease encompasses many other diseases which lead to costly complications throughout life. CV disease can be treated in many ways, including coronary artery bypass graft surgery, angioplasty, and transplants. In 1999, 571,000 coronary artery bypass graft surgeries were performed at $35,000, costing Americans about $19 billion (Wexler, 2003, p. 56). The less expensive alternative, angioplasty, was performed more than 601,000 times in 1999. This procedure’s cost totaled almost $15 billion in the year 1999.

Another example of why individuals should be denied health insurance for self-induced health problems is concerned with cigarette smoking. Cigarette smoking, a known carcinogenic, is perhaps the most controversial insurance risk. It can be said that the previous generation didn’t know the risks of smoking, but in this era there is no excuse. Today, most people are aware of the detrimental effects of tobacco. However, “cigarette smoking continues to be a leading cause of death in the United States. Although studies show that the numbers have decreased dramatically for smokers (48% since 1965), “almost half a million Americans die each year from smoking-related illnesses” (Wexler, 2003, p. 58). Additionally,

From 1995 to 1999, smoking killed over 400,000 people each year… Cigarette smoking is a direct cause of ischemic heart disease, respiratory heart disease, aortic aneurysm, chronic obstructive lung disease, stroke, pneumonia, cirrhosis, and cancer of the liver. Excluding deaths from second hand smoke, males and females lost an average of 31.2 and 14.5 years of life, respectively. Smoking during pregnancy results in an estimated 599 male infant and 408 female infant deaths annually (Huether, 2004, p. 254).

Although there are risk factors that are unchangeable, cigarette smoking nearly doubles the risk of a heart attack. Additionally, 30% of the annual mortalities resulting from coronary artery disease are traceable to cigarette smoking (Huether, 2004, p. 657). Once one has stopped smoking, no matter how long they have smoked, the risk of heart disease decreases dramatically. It is a voluntary lifestyle choice, and since the effects of cigarette smoking are well known, people who choose to smoke are truly taking their life into their own hands. While it is true that less and less Americans are smoking every year, the overall percentage of smokers is about one third. That third of the population is incurring a much larger health bill than the rest of the general population.

Heart disease, hypertension, and type II diabetes are linked together through another pressing American issue: Obesity. Caused by poor diet, lack of physical fitness, and the harried existence of American Culture, America is mired in fat. “In the United States, the incidence of adult obesity increased from 25% in the 1970’s to 64.5% in 2004” (Edelman, 2006, p. 16). There are many different theories as to why people are obese. The clinical manifestations of obesity are as follows:

Obese individuals are at risk for a number of disorders, including coronary artery disease, diabetes, gallstones, hypertension, cardiovascular disease, breast, cervical, endometrial and liver cancer in women; prostate, colon, and rectal cancer in men. Pulmonary function can be compromised by a large amount of adipose tissue overlying the chest cage. Gas exchange, vital capacity, and expiratory volume all decrease, causing low arterial oxygen tension and high carbon dioxide tension (Heuther, 2004, p. 1000).

Statistics show that,

Diabetes type 2 mellitus accounts for 90% to 95% of all diagnosed cases of diabetes… [It] is one of the leading causes of death among Americans and the leading cause of new cases of blindness, kidney failure, and lower extremity amputations, plus it greatly increases a person’s risk for a heart attack or stroke. In 2002 diabetes accounted for more than $132 billion in direct and indirect medical costs and lost productivity (Edelman, 2006, p. 255-6).

With our aging population and rising health care expenses, this is a cost the American people cannot afford to pay. The responsibility again is on the health insurance companies to pay for the results of disease.

Self-influenced diseases are a gray area of health care. They are influenced by the person’s environment, and can be controlled. While a person may have a genetic predisposition for a certain disease, a person's lifestyle can determine whether or not a disease will display. An example is Diabetes Type 2 Mellitus. A lifestyle in which a person eats appropriately and is physically active is less likely to express symptoms than a person who is sedentary who eats a high sugar, high fat diet. Is it the job of the health care industry to pay for every disease? America is torn between whether insurance is a right or a privilege. Currently, it is both. If you can afford health care, it is a privilege. If you are poor, it is a right. However, for the middle class, who make too much to qualify for Medicare/Medicaid and too little to afford private insurance, health care and health insurance is often merely a dream. Rather than look to health care for solutions to self-induced health problems, Americans should begin to take responsibility for their own health. If insurance will not cover diseases related to diabetes type II mellitus, then exercise and healthy diet begin to serve as a better alternative. If smoking related health causes are not covered, then rates of smoking cessation will improve. Whether we realize it or not, we are paying for everyone’s health care with our own money. It is time for Americans to take their health into their own hands, and advocate for healthier lifestyle choices, instead of footing the bill for gastric bypass.

Negative View of Health Insurance Denial

On the contrary, many believe that it is more ethical and ultimately more economical to provide health care and health insurance to everyone without discriminating based on lifestyle choices. Health insurance coverage has historically been a part of the package deal when a person is offered a new job for a career or profession. Just as a retirement fund and vacation days, health insurance coverage plays a key role in feeling a sense of security. If a health issue should arise, an individual could always count on their health insurance to cover the cost. Recently, however, health insurance companies are denying individuals coverage based on lifestyle choices or self-influenced health problems. Specifically, overweight or obese individuals, and those who smoke or drink alcohol excessively are all candidates to be denied health insurance coverage. When denied coverage, individuals have two options. The first option is to pay out of pocket for their own health care, which would likely strain anyone’s budget. The alternative is to forgo medical attention altogether in which case their disease state will likely worsen, causing a multitude of physical and psychosocial issues and ultimately cost the health care system via the Emergency Room.

Based on the latest data from the continuous National Health and Nutrition Survey, 69.7% of Americans are overweight, obese, or extremely obese (NHANES 1999-2000). Preventing chronic diseases associated with obesity can save the health care system billions of dollars. For this reason, it is wise to offer health care coverage to the overweight and obese so that they can receive the medical attention necessary to attain a healthy weight. Avoidable co-morbidities associated with obesity include diabetes, hypertension, and heart disease. It is worth the cost of insuring obese individuals to save costs later, preventing the list of related diseases from multiplying. Recent studies have shown that a 5-10% weight loss reduces the risk of obesity-related co-morbid conditions. This modest weight loss can be achieved through individual counseling sessions with a Registered Dietitian, drug therapy, or visits with a doctor to discuss lifestyle changes. These options should be covered for overweight and obese individuals on the premise of preventing chronic illness associated with obesity. Moderate weight loss can improve glucose tolerance in the diabetic, lower triglycerides and lipid panel, raise high density lipoprotein (HDL) cholesterol and lower low density lipoprotein (LDL) cholesterol. In addition to those clinical improvements, moderate weight loss has a significant impact on a person’s self-image and could likely help them to be more productive at work and take fewer sick days. For these reasons, health insurance should be available to all, regardless of weight.

Smoking, drinking alcohol excessively, not exercising and overeating are all lifestyle choices that people make, and the consequences are not based on genetics. It is known that these choices lead to severe health problems including cancer and cardiovascular disease. Individual behaviors and environmental factors account for nearly 70% of all premature deaths in the United States (Edelman, 2006, p. 232). Even so, it is vital that individuals who want or need medical interventions in order to change their lifestyle habits have access to health care. If they are denied due to lifestyle factors, there is a good chance that they will not be willing or be able to pay out of pocket for the help they desperately need. Without medical attention, disease progression can lead to depression, a lower quality of life, and low self-esteem. Health insurance denial can also be seen as discrimination within a workplace among co-workers, causing social problems. Individuals who are denied coverage and bullied by the powerful health insurance companies are being discriminated against because of their personal, social, and cultural choices.

Solutions for Insurance Coverage of Self-Influenced Health Problems
            It is apparent that there is no easy solution to the dilemma of insurance denial because there are such strong arguments for both sides of the issue. Insurance denial can be directly correlated with the health care system and its solutions for those individuals that are denied. Most developed countries implement a two-tiered health care system, like the United States.  This is a system that guarantees public health care but also has a private sector, which is used by only those who can afford it (Wikipedia, 2007).  The rise in health care costs also affects the cost of insurance, which can result in fewer people with insurance coverage.  There are solutions to the rise in health care problems, particularly self-induced, that have been attempted, such as an increase in premium payments.  There is also much debate over the possible reforms to the health care system to recognize the link between high risk factors and health insurance costs (Thorpe, 2005, p. 1438).
            The most obvious and currently used solution is to increase people’s premiums.  This method operates by measuring the individual's risk factors through the utilization of a survey that insurance candidates have to take.  Their score is totaled and their risk factors are assessed.  The higher the individual's score, the higher the premium they'll have to pay.  In the event that one's risk factor score is too high and they are denied, the State of Washington offers another option for health care coverage.  The Washington State Health Insurance Pool provides health insurance to Washington residents who have been denied coverage.  Their mission statement is "to provide access to health insurance coverage to all residents of Washington who are denied health insurance, by reducing barriers, improving the affordability to the enrollee and member plans, promoting innovative care delivery, balancing costs and benefits, and identifying and implementing key quality measurements." (Washington State Health Insurance Pool, 2007).
            Another possible solution to minimize the number of people who are denied health insurance due to self-induced diseases would be to adopt a universal health care method.  The United States has not yet adopted the universal health care system that Canada currently operates under.  Through this method, all residents of Canada are ensured reasonable access to all medically necessary hospital and physician services on the prepaid basis (Canada Health Act, 2006).  No one is denied health care benefits or coverage.  According to one document, US residents are one third less likely to have a regular medical doctor, one forth more likely to have unmet health care needs, and more than twice as likely to forgo needed medicines (Himmelstein, 2006, p. 1).  Some are hesitant to adopt this method of health care because of the long wait times that Canadians have when pursuing medical care.  A solution to this problem will have to be found before the US will truly consider switching over to a universal health care system.
            Neither of these solutions addresses the underlying problem of why people are denied health insurance.  A reform to the health care system itself cannot solely lower costs or decrease the number of individuals that get denied, without first addressing the root of the problem.  In order "to be effective, reforms should focus on health promotion, public health interventions, and the cost-effective use of medical care” (Thorpe, 2005, p. 1436).  Self-induced risk factors must be the focus of health promotion, which will give people the tools necessary to change poor habits and promote a healthier lifestyle.  This will in turn, lower the cost of health insurance and decrease health care spending.  Since nurses are the primary implementers of health promotion, the issue of insurance denial is directly related to the profession of nursing.
Relevance to the Profession of Nursing
            The nursing profession is greatly affected by the health care system and health insurance. Nursing can have a major effect on the issue of insurance denial by minimizing self-induced health problems through health promotion.  Proper guidance through health promotion and intervention will help reduce the high numbers of self-induced health problems.  Additionally, nurses play a tremendous role in being an advocate for the patient and their health.  As an advocate, “the nurse helps individuals obtain what they are entitled to receive from the health care system, tries to make the system more responsive to client and community needs, and assists client in developing skills to advocate for themselves” (Edelman, 2006, p. 18).  A nurse’s responsibility also includes being an educator.  This involves teaching the clients how to better care for themselves, how to make healthier lifestyle choices, and how to change poor habits and implement positive ones.  The Code of Ethics for Nurses, which was established by the American Nurse Association, emphasizes this role as a health promoter and educator (Chitty, 2005, p. 525).
            Ethics are a big priority for nurses in the twenty-first century.  They provide nurses with the ability to differentiate between which actions would be right or wrong to pursue.  The Code of Ethics also provides the people of our society with a written set of standards that nurses vow to follow when providing care (Chitty, 2005, p. 523).  These ethics include providing our clients with the tools to make healthy decisions for their lifestyle.  If the client is not making healthy choices simply because they lack the knowledge of what to do, then it is our duty as nurses to educate them.
            Another way insurance denial affects nurses is the actual insurance reimbursement to the facility the nurse works for.  If the client comes in for treatment and is not insured due to their high risk factors, then the responsibility to repay the incurred bills fall on the hospital and community.  The individuals with insurance, however, have their insurance companies reimburse the hospital for the care received and as a result the nurse and other faculty members get paid. Reimbursement is a big factor for third party payers or insurance companies and the contract that they have with the individual (Chitty, 2005, p. 422).  As a result, individuals with higher health risk factors must pay higher deductibles and co-pays so that the insurance company is able to reimburse the health care facility.
            The factors described above greatly influence nursing care and how medical treatment is provided.  As a result of the high health care costs, nurses are forced to limit their level and quality of care to clients (Chitty, 2005, p. 440). In other words, costs not only affect health insurance, but nurses and their profession as well.  It is part of the nurse’s role to make sure clients receive all of the information applicable to their current situation, even if it is self-induced.  Providing client care is one of the main reasons the nursing profession is utilized today.  Anything that affects the patients, directly or indirectly affects the nurses who would be providing their care.
            The issue of insurance denial and self-influenced health problems is a growing concern for many Americans.  It directly affects the cost of everyone’s health care and health insurance. It also questions the justness of the insurance system and whether it is ethical to accept high risk individuals and raise the cost for insurance and health care for others, or deny these individuals and discriminate based on their lifestyle choices.  Additionally, should each individual be responsible for their own health, or should they be allowed to rely on the health care system to care for their diseases and the consequences of their risky behaviors?
            Supporters for denying insurance of self-influenced health problems argue that denial of insurance to high risk individuals will lower health insurance costs and health care costs.  As a result, health care and insurance will be more affordable and available for those who currently cannot pay for it.  Additionally, denial of insurance coverage might motivate individuals to alter their lifestyle to improve or maintain their health.  Forcing people to take incentive for their own health will result in an overall healthier population and fewer quick-fixes provided by the health care system.
            The argument for health coverage of high risk individuals is that it should be the right of all individuals to receive health care and insurance regardless of their lifestyle choices.  Medical services to improve health should be available to all, whether or not it is for the treatment of self-induced problems.  Also, the cost of not covering high risk individuals could ultimately result in a higher cost for the general population to pay if the denied individual goes without health care until the condition becomes extremely life-threatening and costly.  In which case, the individual’s inability to pay the expense out-of-pocket is deferred to the hospital, further raising the cost of health care and insurance.
            As a group, our point of view in response to the issue is in favor of insurance denial for self-induced health problems such as smoking, obesity, heart disease, and diabetes.  While we do not feel that individuals should be completely denied health insurance based on their high risk behaviors, it is appropriate for insurance companies to charge higher rates for coverage or deny coverage for services directly related to the self-influenced problem.  This approach will have a positive benefit on society in terms of lowering health care costs and insurance costs.  In addition, people will become more accountable for their own health maintenance.  This solution will begin to improve our health care system as a whole and make services more affordable and readily available to those who currently do not have health insurance.  Resolving the issue of insurance denial and self-influenced health problems is one step toward the betterment of the American health care system.


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