7/22/2011

Negative View of Health Insurance Denial

Negative View of Health Insurance Denial

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..
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