This post is a part of our Bioethics in the News series. For more information, click here.
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 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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