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December 13, 2010


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I have two issues with your analysis that stem from my conception of Kantian ethics. First, it is far more than unclear that those with "pre-existing conditions" are responsible for paying for them, for the simple reason that it is almost certainly the case that those with "pre-existing conditions" are not responsible for the existence of those conditions. After all, no one would intentionally choose to be severely ill or incapacitated.

Who is responsible for them? Again, I don't buy the claim that other people are not. Causal analysis of the most costly illnesses, such as various types of cancer, often reveals that the surrounding or upstream/upwind communities are at least partly responsible, through the pollution they emit. Otherwise, these sorts of illnesses or injury are the result of unforeseeable acts of Nature. I think one can make an argument that it is the entire community of moral agents that is responsible for unforeseeable acts of Nature, at least in terms of retribution.

Therefore, it makes sense to use a variation of taxes to pay to fund the treatment of this kind of medical care. Think of it like this: The mandate says you have to pay a tax to pay for financing other people's medical care (and maybe your own in the future), but you get an exemption from that tax if you own health insurance.

The second issue I have is with the concept of "pre-existing conditions" as it is used by insurance companies, and is used in your analysis. This concept is one invented by insurance companies to deny covering treatment, so long as they can find evidence that the illness or precursors to the illness existed prior to the insurance contract. But this is virtually always the case, especially in serious illness.

This is acting in bad faith for several reasons, but I'll highlight the biggest problem below. People buy insurance so that they will be covered when they need it, but the insurance comes with terms and the insurance only pays for treatments, not for disease. You only have coverage as long as you pay, most people can only pay when they have a job. But when are not yet ill enough to have to quit, treatments are not (yet) expensive. As soon as you have to quit, you lose your ability to pay, so you lose your coverage for treatments for that illness. Moreover, you can no longer get coverage because it's suddenly a "pre-existing condition."

As long as insurance companies only pay for treatments occurring within their terms, and not for curing diseases that occur within their terms, "pre-existing conditions" is a concept that relegates patients to mere means for the profit-seeking ends of insurance companies.

Thanks for the long and thoughtful comment, Nathan. Here are my thoughts in response:

  1. I agree that responsibility usually derives from causal action--we're responsible for what we voluntary do--but if no cause for a pre-existing health condition can be determined, the responsibility would fall (tragically) on the sufferer, if only because no one is causally responsible either (as the tort system treats liability). (And if some party can be found responsible, then the tort system can provide compensation for that.)

  2. My point with insurance for pre-existing conditions was that it made no sense, regardless of the bad faith (or not) of insurance companies. There can be no insurance (literally) for pre-existing conditions--just care. Of course, it does become more complicated when one loses or changes jobs, but that is an implication of employer-based health insurance, which is an artifact of history. If we could sever the link between employers and health care, then people would not be afraid to leave or change unsatisfactory employment simply for fear of losing their insurance (or the coverage of conditions which will become pre-existing ones under new insurance).

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