Should Women Pay More for Health Insurance?

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By Leonard M. Fleck, Ph.D.

In a recent commentary in Time (Aug. 23, 2013), Hadley Heath argued that women ought to pay more for their health insurance than men. Fairness, she contended, required this. She was criticizing the requirement of the Patient Protection and Affordable Care Act [PPACA] that prohibited unequal insurance premiums for men and women. There seemed to be two primary reasons for her view: (1) Women live longer than men; (2) Women consume more health care than men. I will start by accepting both these statements as factually true. But I find deeply problematic the normative claim that women are not paying their fair share of health care costs.

Behind Ms. Heath’s normative conclusion is a premise for which she offers no argument. If I buy a more luxurious car, a larger home, or finer wines, then I ought to pay more for these goods than individuals who are content with a used Chevy, a 1000 square foot ranch home and Boone’s Farm. If I consume more health care because I have colorectal cancer and late-stage heart failure, then I ought to pay more for my health care than someone with a broken arm from falling off their polo horse. That is, needed health care should be thought of as just another consumer good, not as anything morally special. If someone wishes to use more health care, then they ought to pay more for that health care.

The wording in that last sentence ought to get our attention. Who is it who “wishes” to use more health care for their cancer and heart disease? Do I wish to use more health care in the way that I wish to have a second piece of turtle cheesecake? The very asking of the question makes manifest its absurdity. I need health care for my cancer or heart disease unless I am willing to accept a premature and painful death. This is what motivates us to think of needed and effective health care as being morally special instead of as just another consumer good to be distributed in accord with desire and ability to pay.

There is another unstated principle in Ms. Heath’s essay that is even more morally troubling than my first point. It is that those who use more health care, or are likely to use more health care, ought to pay more for that health care (or be denied it.) At any point in time the vast majority of women in our society are in excellent health, so it seems there is something silly about this whole debate. However, a large fraction of the uninsured and uninsurable in our society have that status because they have (or are likely to have) very costly health problems which insurers will not cover or for which insurers will charge unaffordable premiums. This is not a silly or trivial problem. At the moral core of the PPACA is the rejection of the idea that individuals with greater health needs must pay for their health care in proportion to need. That is the principal Ms. Heath is really attacking. Women are being used by her as a Trojan horse for attacking the moral fortress of the PPACA.

Finally there is the issue that women live longer than men on average. Again, the principle seems to be that if one lives longer, then it is assumed (maybe falsely) that one will use more health care during those extra elderly years. If that is the principle, however, then there is no good reason why women alone should bear those extra insurance costs. Rather, all persons who can be reliably predicted to achieve greater than average life expectancies ought to be saddled with extra insurance costs. This is hardly the sort of message we would want to give to citizens whom we are encouraging to make healthy lifetime choices for a longer life. The predictable outcome of such a message would be that economical men would rationally choose to spend yet more time watching sports on TV and guzzling beer while gulping down burgers and brats. Does that yield the logical conclusion that women should be charged more for health insurance?


Leonard FleckLeonard M. Fleck, Ph.D., is a Professor in the Center for Ethics and Humanities in the Life Sciences at Michigan State University and the author of Just Caring: Health Care Rationing and Democratic Deliberation.

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7 thoughts on “Should Women Pay More for Health Insurance?

  1. In addition to Dr. Fleck’s cogent points I believe that much of the extra costs of health care for women are related to pregnancy. Until and unless men no longer have any role in that, it seems specious to make the argument for a great deal of the differential cost.

  2. (1) The factual basis for the claim is weak: It is true that women live 4-5 years longer than men on average, but longevity has little to do with the PPACA, since that is mainly aimed at re-organizing the private insurnce market, which target largely people under 65. It is Medicare, where longevity differences matter.
    (2) It is also questionable whether insurance rates should differ based on criteria that simply describe who we are rather than what we do. It would be one thing to charge some people more to discourage behaviors that lead to ill health (smoking, overeating, lack of phsyical activity–assuming we could reliably monitor such behavior), it is another to charge poeple more, even though they can’t do anything about their status.
    (3) A more general objection against charging different population groups different insurance rates is that it ultimately defeats the purpose of insurance, which is to defray the costs of unpredictable individual health care needs over a large population group. If we slice and dice the population into numerous “risk groups” we end up with a system in which the healthy have low rates and some have very high rates, as is the case for people with “pre-existing conditions.”

  3. it’s true–women live longer than men. It’s also true that many of those women spend some time before they die taking care of the frail old men who die before them. When we figure out how to put a price on the value of that unpaid, often quite skilled home care labor, let’s talk again about charging the longer lived ladies for insurance premiums. But not before.

  4. I have not read the article by Hadley Heath to which you refer, but the intent seems rather obvious. Heath is referring to what is commonly called the “insurance principle”. Under the principle a group of people share a risk; i.e., they sacrifice a little (the premium) in hopes of not incurring a catastrophic loss. No one “wishes” to be the one to incur the loss, but if they are the unfortunate one, then it was worth the risk or sacrifice. However, to be fair to everyone, the premium may be adjusted if greater risk is involved. You mention the ‘luxurious car’ and the ‘larger home’. These entail greater risks (payouts) and call for larger premiums. The same goes for life insurance.
    It would seem to me that while we might find room for disagreement with Heath we should not trivialize her argument. The point is that she believes women statistically are higher risks to make a claim for health benefits. Thus, they should pay a higher premium. That is a woman, as a woman, enjoys the benefits of lower “life insurance” premiums and it seems equitable and just to Heath that the corollary is that they should pay higher “health insurance” premiums. I would not want to put words into Heath’s mouth but I would think that she would ask “we are talking about health insurance aren’t we?”

  5. Moreover, the point of insurance is to spread risk, as is recognized by community rating. In contrast, medical underwriting attempts to make insurance payments reflect risk. The ad absurdum consequence is that each of us pays to the insurance company exactly what we can be expected to cost in expenses. This is silly, and leads to the immoral health insurance system most of us in the US have been living with.

  6. It seems that this argument can be further generalized. If women cost more (and I am not sure that is true) than so do older people and individuals (including children) with medical problems.
    The concept of insurance is that the many pay for the few. Most people do not use as much money as they pay in or all insurance companies would go under.
    The question here whether health insurance is a right or a privilege. Do we indeed have a moral obligation to provide for those in our society that are in need of help.
    Furthermore, while it is true that one person may buy a cadillac and another a chevy, all people buying the cadillac pay the same for that car.
    It likely makes sense that certain services be either excluded from health care coverage (those which are purely optional and cosmetic) or that policies covering those services could perhaps cost more for the covered individual.
    But basic health care ought to be a right for everyone. People at greatest risk should not be paying more to get services anymore than children with learning disabilities should pay more for education.
    Finally, it is unlikely that women are greater users of health care dollars in general since it is well known that men have more health care issues overall.

  7. I am appreciative and supportive of Dr. Fleck’s remarks (and not just as an MSU alum). However, in reading Ms. Heath’s article, I am far more concerned by the notion that we should face men’s health issues by simply offering them a discount in healthcare as a process. If we are losing our men sooner, in greater numbers, and more tragic ways, I believe there is a need for a far more compassionate response. How do we find ways to encourage men to be pursuers of preventative care and how do we begin to encourage communities to speak to important – but uncomfortable – issues?

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