# The ethics of health insurance **URL:** \ **Category:** Miscellaneous and Personal Stuff I Must Share\ **Created:** [December 5, 2024, 3:45am UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177 "2024-12-05T03:45:03Z")\ **Posts on this page:** 18\ **Page:** 18
**Author:** ![Dr.Strangelove](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dr.strangelove/32/6613_2.png) [@Dr.Strangelove](https://boards.straightdope.com/u/Dr.Strangelove)\ **Post date:** [January 7, 2025, 7:30am UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/341 "2025-01-07T07:30:13Z")
Keep sliding those goalposts. They’re almost out of sight. ---
**Author:** ![Thing.Fish](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/thing.fish/32/9168_2.png) [@Thing.Fish](https://boards.straightdope.com/u/Thing.Fish)\ **Post date:** [January 7, 2025, 7:31am UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/342 "2025-01-07T07:31:15Z")
Your head is almost out of sight. ---
**Author:** ![Dr.Strangelove](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dr.strangelove/32/6613_2.png) [@Dr.Strangelove](https://boards.straightdope.com/u/Dr.Strangelove)\ **Post date:** [January 7, 2025, 7:37am UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/343 "2025-01-07T07:37:03Z")
Seriously, what are you even trying to claim here? People with Munchausen’s Syndrome pretend to be sick in to gain attention, wasting healthcare services in the process. Are you trying to dispute that? ---
**Author:** ![wolfpup](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wolfpup/32/10618_2.png) [@wolfpup](https://boards.straightdope.com/u/wolfpup)\ **Post date:** [January 7, 2025, 7:43am UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/344 "2025-01-07T07:43:58Z")
> [@Dr.Strangelove](#): > > But on the other hand, public prescription coverage in Canada does have co-pays essentially everywhere. I still have not gotten an explanation for why these would be necessary except to avoid the moral hazard. I don’t consider a $4 dispensing fee (which some pharmacies may choose not to even bother charging) to be any kind of disincentive. But anyway, on your original subject, here we go – an example of “moral hazard” avoided: 🙄 > [@My achin' dry eye eye eye](https://boards.straightdope.com/t/my-achin-dry-eye-eye-eye/1012667/1): > > She prescribed me the first stage of treatment eye drops. Restasis, cool not zydra or Mibo, both being flogged on tv, so new and stupid expensive. Well, when I called the pharmacy, the _co-pay_ for this stuff is 300+ dollars. Yikes! We cannot afford that. ---
**Author:** ![Dr.Strangelove](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dr.strangelove/32/6613_2.png) [@Dr.Strangelove](https://boards.straightdope.com/u/Dr.Strangelove)\ **Post date:** [January 7, 2025, 7:55am UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/345 "2025-01-07T07:55:08Z")
> [@wolfpup](#): > > I don’t consider a $4 dispensing fee (which some pharmacies may choose not to even bother charging) to be any kind of disincentive. This basic style of argument is not convincing to me (i.e., “no one will start/stop doing X just because of some [nominal fee]”). Consider the claim that no one who can afford a Porsche would care about raising the price a single dollar. And yet: - There are some fair number of people will buy a Porsche for $100,000 - There is almost no one that would pay $10,000,000 for a Porsche But what if you increase the price of the car by $1 at a time? At various points in this process, the number of people willing to buy the car will decrease. So wherever the threshold actually is, there is some number where raising the price $1 causes someone to drop out (and really there will be many such points). And before you try to claim “well, sure, maybe there’s some higher threshold, but at $100k no one will care”, that just makes the problem _worse_, because you’ll still end up with a situation where there’s some number that will pay $354,792 and some _lower_ number that will pay $354,793. There’s no way around this. ---
**Author:** ![Dr.Strangelove](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dr.strangelove/32/6613_2.png) [@Dr.Strangelove](https://boards.straightdope.com/u/Dr.Strangelove)\ **Post date:** [January 7, 2025, 8:10am UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/346 "2025-01-07T08:10:27Z")
> [@wolfpup](#): > > But anyway, on your original subject, here we go – an example of “moral hazard” avoided: 🙄 Hmm: > **[cdr\_trans\_Restasis\_plr\_Sept-2-11\_e.pdf](https://www.cda-amc.ca/sites/default/files/cdr/relatedinfo/cdr_trans_Restasis_plr_Sept-2-11_e.pdf)** > > 269.00 KB > Recommendation: > The Canadian Expert Drug Advisory Committee (CEDAC) recommends that Restasis, which is also called cyclosporine ophthalmic emulsion, not be listed by Canada’s publicly funded drug plans for the treatment of moderate to moderately severe dry eye disease. Seems like it’s barely better than the alternatives but way more expensive. Even with standard Canadian drug prices, this seems like a lot: > The daily cost of Restasis ($6.33) is significantly higher than the daily cost for other treatments used for dry eye disease: artificial tears ($0.18 to $0.39), topical corticosteroids ($0.28 to $1.24), and topical non-steroidal anti-inflammatory drugs ($0.51 to $2.51). ---
**Author:** ![Broomstick](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/broomstick/32/246_2.png) [@Broomstick](https://boards.straightdope.com/u/Broomstick)\ **Post date:** [January 7, 2025, 8:58am UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/347 "2025-01-07T08:58:51Z")
> [@doreen](#): > > Health insurance companies won’t pay if someone else is liable. Yes. That’s called sub-rogation and all insurance companies, not just the health ones, love love love to use it to avoid paying at all costs. However, having worked for the Evil Insurance Empire and having seen the fine print on health policies some absolutely will cover your kid if your kid gets hurt at school, including while playing sports. I also know this from personal experience. When I injured my knee playing high school soccer my family’s medical policy covered me. On the other hand, one of my co-workers at one point in my life took out a separate policy to cover his daughter while doing gymnastics. Most people, though, never read the fine print. Back when I was actively flying I used to insist on getting a copy of the full policy so I would know if the policy covered me in general aviation aircraft or if I’d need to get a separate policy for that. Remarkably, during about half that time my employers’ policy _would_ cover that. > [@doreen](#): > > In my case, the benefits are likely better than the commercial policies but that won’t be the case with all self-insured employers. In my experience it is VERY rare for self-employed companies to have better policies than standard commercial policies. Particularly for smaller employers. ---
**Author:** ![Broomstick](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/broomstick/32/246_2.png) [@Broomstick](https://boards.straightdope.com/u/Broomstick)\ **Post date:** [January 7, 2025, 9:23am UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/348 "2025-01-07T09:23:53Z")
> [@Dr.Strangelove](#): > > Not “fun”, but inappropriate use of the ER is absolutely a problem. Of course there’s a moral hazard for a service that’s “free” to the patient but has great cost to provide. One significant reason in the US for “inappropriate” use of the ER is because some people have no other recourse for health care. > [@wolfpup](#): > > Public health care protocols should not be based on the behaviours of a few mentally ill people who are easily identified and appropriately dealt with. ^ This. > [@Dr.Strangelove](#): > > And the kind of attention you get is more public and intense in the ER than sitting quietly in a clinic. Have you ever actually _been_ in an ER? Unfortunately, I have. You generally get seen sooner in a clinic. Waits in an ER can be _hours_. Even the better part of an entire day. I could see a homeless person on a cold day/night camping out in the ER just to stay warm (when my husband was dying I actually did see that once - on a night with horrible weather, even by Chicago area standards, the ER opened a conference room with chairs for homeless folks to warm up in. Which was probably cheaper to society overall, not to mention better for the human beings in question, than waiting for them to suffer frostbite or some other cold injury that actually required treatment). That’s different than being in an ER for “attention”. > [@Dr.Strangelove](#): > > I’ll bet you get attention faster if you scream and writhe around on the floor. If they think you’re faking it they might just ignore you. Nope, just doesn’t hold water. First of all, when you do get “attention” in an ER you’re in a treatment bay behind a curtain, it’s not “public”. Based on my own life experience, unless you are in imminent danger of death (and no, you _don’t_ want them to jump you to the head of the line, that’s Bad Sign) being in the ER means being alone in a cubicle, completely ignored for long periods of time while the personnel are attending to someone in more urgent need. > [@Dr.Strangelove](#): > > Incidentally, that whole system seems hilariously complicated even compared to American healthcare. Having worked in “American healthcare” - no, it’s not. It’s MUCH simpler and certainly more transparent that the jacked-up “system” we have here. Although not as simple as the Canadian system. ---
**Author:** ![Dr.Strangelove](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dr.strangelove/32/6613_2.png) [@Dr.Strangelove](https://boards.straightdope.com/u/Dr.Strangelove)\ **Post date:** [January 7, 2025, 9:40am UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/349 "2025-01-07T09:40:04Z")
> [@Broomstick](#): > > Have you ever actually _been_ in an ER? Yes (I had to wait for hours while in excruciating pain from gallstones). But I sat there quietly and assumed there was some triage process. Remember, the context here is people with Munchausen syndrome. They will yell and scream and even [add chicken blood to their urine](http://news.bbc.co.uk/2/hi/health/3197248.stm) just to get someone to pay attention to them. How normal people behave is completely irrelevant to the point I was making there. And whether the person gets actual medical attention or just attention from hospital security is likely also irrelevant. It’s a type of narcissistic personality disorder. They just want to be the center of attention at all times. And hospitals are great places to make yourself the center of attention. > [@Broomstick](#): > > Having worked in “American healthcare” - no, it’s not. It’s MUCH simpler and certainly more transparent that the jacked-up “system” we have here. I just meant from the end-user perspective, not whatever bookkeeping there is on the insurance side. But Canadian healthcare is certainly simpler yet. ---
**Author:** ![Spoons](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/spoons/32/3141_2.png) [@Spoons](https://boards.straightdope.com/u/Spoons)\ **Post date:** [January 7, 2025, 9:48am UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/350 "2025-01-07T09:48:07Z")
> [@wolfpup](#): > > Doctors’ offices here don’t have any facility for accepting credit cards, or any need for such. Well, they might. An American friend in need of care while visiting, found that a walk-in clinic wouldn’t accept her American health insurance, and pulled out their “swipe-swipe” machine for her Visa or Mastercard. But they filled out the forms, gave her a receipt, and she could claim the amount on her US insurance when she got back home. Which happened, eventually. Point is that doctor’s offices in Canada might have a dusty “swipe-swipe” credit card machine, unused for years, for just such incidents. ---
**Author:** ![doreen](https://avatars.discourse-cdn.com/v4/letter/d/858c86/32.png) [@doreen](https://boards.straightdope.com/u/doreen)\ **Post date:** [January 7, 2025, 1:11pm UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/351 "2025-01-07T13:11:54Z")
> [@Dr.Strangelove](#): > > Remember, the context here is people with Munchausen syndrome. They will yell and scream and even [add chicken blood to their urine](http://news.bbc.co.uk/2/hi/health/3197248.stm) just to get someone to pay attention to them. Some will do that - but the sort of attention that most people with factitious disorder are seeking is not the sort gained by yelling and screaming in the ER waiting room. Which will not get them seen more quickly. And policies shouldn’t be made based on a disorder that has a lifetime prevalence of maybe 1% (most likely lower) in the general population. Especially since charging a copay _isn’t going to change the behavior_ of people with that sort of mental illness. You can steer me to regular preventive care or urgent care instead of emergency room care by different co-pays (which absolutely does happen) and it’s possible that might be appropriate in a given system. But even that is not based on the idea that people will seek medical care for no reason at all - it’s to discourage people from putting off seeking care because they are trying to avoid the doctor visit that will cost the same $25 as the ER visit. ---
**Author:** ![DavidNRockies](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/davidnrockies/32/6279_2.png) [@DavidNRockies](https://boards.straightdope.com/u/DavidNRockies)\ **Post date:** [January 7, 2025, 1:31pm UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/352 "2025-01-07T13:31:51Z")
I willfully skipped over the last few dozen posts, but … I think the “moral hazard” argument isn’t that free healthcare means people will unnecessarily abuse the healthcare _system._ I think, instead, it implies that people are _less incentivized_ to optimize their own lifestyle choices and improve their health … because … the backup options are free. The same ‘risk compensation’ discussions happen in numerous realms – bicycle helmets, automobile safety features, etc. I’ve never looked into it to see if there’s any data to support these things, but … US healthcare bankrupts Americans with a cold indifference and an insatiable appetite as we get sicker and sicker and sicker, so … my visceral reaction is to hypothesize that what we’re currently doing … ain’t working for the healthcare _consumers._ If ‘free’ at point of service really created a powerful moral hazard, then it would likely increase revenue and profits across the industry, and why should we assume the industry _wouldn’t_ want that? Back to you in the studio, Gail… ---
**Author:** ![puzzlegal](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/puzzlegal/32/3827_2.png) [@puzzlegal](https://boards.straightdope.com/u/puzzlegal)\ **Post date:** [January 7, 2025, 2:02pm UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/353 "2025-01-07T14:02:42Z")
> [@Dr.Strangelove](#): > > > [@puzzlegal](#): > > > > You don’t have several doctors looking at you in the ER, although you might get shunted from one doctor to another, with a long wait in between. > > The point is that Munchausen types want _attention_. And the kind of attention you get is more public and intense in the ER than sitting quietly in a clinic. > > I’ll bet you get attention faster if you scream and writhe around on the floor. Cite that care is more public or more intense at an emergency department? > [@Broomstick](#): > > Nope, just doesn’t hold water. First of all, when you do get “attention” in an ER you’re in a treatment bay behind a curtain, it’s not “public”. Based on my own life experience, unless you are in imminent danger of death (and no, you _don’t_ want them to jump you to the head of the line, that’s Bad Sign) being in the ER means being alone in a cubicle, completely ignored for long periods of time while the personnel are attending to someone in more urgent need. My experience, in three local emergency rooms, is that you get parked in an empty room, and then sit there alone. > [@Dr.Strangelove](#): > > > [@Broomstick](#): > > > > Have you ever actually _been_ in an ER? > > Yes (I had to wait for hours while in excruciating pain from gallstones). But I sat there quietly and assumed there was some triage process. Remember, the context here is people with Munchausen syndrome. Yes, in the ED, instead of taking to a receptionist who checks to see if you have an appointment, you talk to a nurse who triages the patients. Then you sit in a waiting room, which is exactly as public as a clinic waiting room, and less public than the open space at a mall. Then you are taken to a room to get seen by someone trained to diagnose your symptoms. (The three emergency rooms I’ve been to near here had rooms, not curtained off cubbies. But medical privacy times require you be apart from the public at this stage.) Once they decide you are stable (you are not currently in cardiac arrest, it is, indeed, a broken bone, the problem with your eye is not going to get irreparably worse in an hour or two) they leave you parked in that room, alone, while they tend to other emergencies. When i thought i was having a retinal detachment, i waited a few hours, alone, until someone put me in a wheelchair and wheeled me to the 24 hour ophthalmology clinic, when they could have just told me to walk there as soon as i was triaged. (The ophthalmology clinic told me to go there, and not to the ED, if i had further need of emergency care. Also, it was just a vitreal detachment, but they have very similar initial presentations, and i had two friends with recent retinal detachments. Which is why I sought emergency care. And some of those visits were for my mom, in her last years.) > [@Dr.Strangelove](#): > > I’ve never had to submit anything to anyone for reimbursement I have. Lucky you. ---
**Author:** ![Dr.Winston\_OBoogie](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dr.winston_oboogie/32/2945_2.png) [@Dr.Winston\_OBoogie](https://boards.straightdope.com/u/Dr.Winston_OBoogie)\ **Post date:** [January 7, 2025, 2:34pm UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/354 "2025-01-07T14:34:36Z")
> [@wolfpup](#): > > No one goes to the doctor or to the ER for the fun of it. We have no deductibles and no co-pays for medically necessary procedures. No “moral hazard” has been observed. Yet in the US, co-pays and deductibles exist for these procedures, even if they’re life-saving necessities. Why? Unfortunately, it comes from abuses of the system changing systematically. A long time ago, they started covering doctor’s office visits. Someone came up with the idea of “let’s encourage regular checkups to keep people healthy so we don’t pay hospital bills down the line”, so they made doctors visits paid 100%. People showed up at the doctor with sniffles, so they added a copay so people had to be sick enough to be willing to pay something. Meanwhile, ER care was paid 100% because, well, it’s an emergency. So, people would go to the ER because it’s free rather than a $20 physician copay. So, they changed to $100 ER copay; waived if you are admitted overnight. Lather, rinse, repeat. Some of that is also the profit motive of the insurance companies. “Hey, we’re paying 100% for ERs at hospitals that don’t like us. Why not only cover ER visits at hospitals in network (HMO), or only 50% for out-of-network (PPO)?”, or better yet, “We’re only paying for doctors that are in-network”, which led to people getting full bills from their anesthesiologist who wasn’t in network but the patient didn’t get to choose. Abuses like that from the insurance carriers get “fixed” (maybe) in the state legislature, so you have 50 different rules, depending on where you live. I’m sure that when they first installed Universal Health in Canada, there were similar abuses. But, once people became used to it, the abuses tailed off. Now, 50+ years later, it’s evened off, and running smoothly. Hell, I’m sure there are plenty of Canadians who run to the doctor with the sniffles, but because Canadians aren’t as self-centered as Americans, no one bitches about it. > [@wolfpup](#): > > I still have not gotten an explanation for how drugs that are only available under a doctor’s prescription can be abused for fun & profit. Well, not quite fully explaining, but… Again, in the US with the profit motive behind so, so many things, there is a huge difference between brand and generic costs. Again, historically, it started out as “No copay for Generics; $10 copay for Brands” to dis-incent Brand usage. Then the desire to lower costs hits, and you get “$10 copay for Generics; $50 for Brands” or “$10 generic / $20 for preferred brands / 50% for non-preferred brands” (don’t get me started on drug rebates paid to the PBMs to get drugs on the preferred list) ---
**Author:** ![Zyada](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/zyada/32/3028_2.png) [@Zyada](https://boards.straightdope.com/u/Zyada)\ **Post date:** [January 7, 2025, 2:42pm UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/355 "2025-01-07T14:42:08Z")
Have you ever been to a hospital for any surgical procedure? That “I don’t have to submit any paperwork” isn’t as helpful when you get bills from different providers for months afterwards ---
**Author:** ![Zyada](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/zyada/32/3028_2.png) [@Zyada](https://boards.straightdope.com/u/Zyada)\ **Post date:** [January 7, 2025, 2:48pm UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/356 "2025-01-07T14:48:01Z")
> [@Dr.Winston\_OBoogie](#): > > A long time ago, they started covering doctor’s office visits. Someone came up with the idea of “let’s encourage regular checkups to keep people healthy so we don’t pay hospital bills down the line”, so they made doctors visits paid 100%. People showed up at the doctor with sniffles, so they added a copay so people had to be sick enough to be willing to pay something. Meanwhile, ER care was paid 100% because, well, it’s an emergency. So, people would go to the ER because it’s free rather than a $20 physician copay. So, they changed to $100 ER copay; waived if you are admitted overnight. Lather, rinse, repeat. Some of that is also the profit motive of the insurance companies. “Hey, we’re paying 100% for ERs at hospitals that don’t like us. Why not only cover ER visits at hospitals in network (HMO), or only 50% for out-of-network (PPO)?”, or better yet, “We’re only paying for doctors that are in-network”, which led to people getting full bills from their anesthesiologist who wasn’t in network but the patient didn’t get to choose. Abuses like that from the insurance carriers get “fixed” (maybe) in the state legislature, so you have 50 different rules, depending on where you live. Wrong. ERs get abused because people don’t have health insurance at all. If you don’t, and your kid has a broken arm, you have the choice between the ER, or nothing. All the rest of this just argues for eliminating co-pays ---
**Author:** ![thorny\_locust](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/thorny_locust/32/431_2.png) [@thorny\_locust](https://boards.straightdope.com/u/thorny_locust)\ **Post date:** [January 7, 2025, 7:40pm UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/357 "2025-01-07T19:40:12Z")
> [@Cervaise](#): > > The doctor prints the paid invoice, stamps it, and signs it, again on the spot. > > The doctor hands the paper to me. > > I then mail it to the CNS (our national healthcare oversight agency) with a claim form, which includes my personal banking information (like the IBAN). > > Seven to ten days later, I get a response in the post confirming processing for reimbursement. > > And two or three days after that, that money reappears in my bank account. > > That’s it. No co-pay or anything else. I pay the doctor directly, and then the state reimburses me. What happens if the cost of the medical care is more than you’ve got in your bank account? ---
**Author:** ![Dr.Strangelove](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dr.strangelove/32/6613_2.png) [@Dr.Strangelove](https://boards.straightdope.com/u/Dr.Strangelove)\ **Post date:** [January 7, 2025, 9:17pm UTC](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177/358 "2025-01-07T21:17:36Z")
> [@puzzlegal](#): > > Cite that care is more public or more intense at an emergency department? 🤷‍♂️ Just an impression, I guess. My local urgent care clinic is a tiny little thing in a strip mall that hardly ever has anyone in it. If my goal was to make a scene, that wouldn’t be the place. > [@puzzlegal](#): > > My experience, in three local emergency rooms, is that you get parked in an empty room, and then sit there alone. My (one) experience is that I sat in a big room for a long time before anyone would see me at all. Plenty of people milling about, though. Some were getting care more urgently than others. Eventually someone saw me. Can’t remember if I’d been fully diagnosed at that point, but I was put on a gurney and left in a (busy) hallway. I’d almost say I was forgotten about but when I tried to use my cell phone to call mom (“hey, you’ll never guess where I am…”) a nurse stopped by and told me to quit it, I’m interfering with all the electronic medical devices. Anyway: still lots of people about, so if I wanted to make a scene that would be another good place. Except for the short time in the ultrasound room, I never had more privacy than a thin curtain until I was placed in an actual hospital room. [Previous page](https://boards.straightdope.com/t/the-ethics-of-health-insurance/1011177.md?page=17)