T he abuse of insurance ° lin Woodyard T he re are times, while
completing the stir trivial rounds and common tasks of sii-gerY, when one wonders if health in- ,-,,a,nee is not becoming a social curse se- Ai–ilisu only to inflation and unemployment. ii,.1,11°.lign the provision of medical care in w'"ain and the US differs greatly in many ihaYs' they have this at least in common —h e problem of paying for it all. Bot sYstents are financed by insurance, steadily demand in cwith ost and failing to reconcile infinite Mena finite income. Two pheno- ena seem worth examining. The first is the influence of insurance on accident -eur prevention and the medical se- h,:e. of accidents, nowhere better seen ta,-"ii in the road accident epidemic. The stn•atability of insurance, plus our rather rPPY social attitude to the need for so`sPonsibility on the road, allows the per.- heri who causes a road accident to escape, if so wishes, all the really painful and per-f his resPonsibility for the consequences o , . carelessness or stupidity. If injured, the griiver ( z (only too often unemployed or under ir or both) is spared even a representative 4tonally, of his own medical costs. Tradi- 7Y, insurance lays off the risk for what 'sftuought of as unavoidable disasters and in111-0'itturles is it really to our benefit for Drt '''Y off all the risks of avoidable and ft edictable accidents and to settle all the Ilwankcial consequences of people's folly? ed Here industrial accidents are concern- % i insurance (now obligatory on Personal) may or not remove a sense of t'?rial responsibility in employers and ao`13.10Yees to try to prevent any and every dentc1rient but it has long been known to ac- enc „ but
and family doctors that it s'urages delay in return to work.
ovet3ine time ago I reviewed the records of of si,°° People claiming compensation — quarters with trivial injuries only three
and were back at work in six months -''' aft
were er a Year ten per cent of the total brt'; still not working. There were no bruits en bones in this group; only cuts, likeises, sprains, wrenched backs and the 4141 It au was hard not to believe that national tionree and the prospect of compensa- .r,were delaying return to paid work. rim", is is not to deny for one moment the soro'ness of compensation for the results of thatthaseb°dY's negligence, merely to observe Ihe Possibility of compensation for"gri insurance leads to a certain laissez- erri_r, attitude on the part not only of some atIc11°Yees but also of the less intelligent ly sonItUaginative management. The relative- tioorrit Health and Safety at Work regula- Rrek...unPlicitly recognise the need for Preve" In-essure to be put on employers.to ilt Inhlry, since employer's liability in-
surance itself conveniently offloads this responsibility. Insurance, even if it does not encourage, certainly allows irresponsibility, both in those who can prevent injury as well as those who are injured.
The second related phenomenon between insurance and health care is perhaps even more topical and concerns private health care. This was for years a fringe activity in this country, pottering along quite nicely, breaking even financially and sheltering the AB readership from the brute realities of the NHS; but this year BUPA, rapidly ex- panding in private health care, has shown for the first time an underwriting loss.
There must be many reasons for this: first, a failure to anticipate extra demand when taking on a much wider selection of potential patients than before. With the very popular bulk schemes now being run, social classes III and IV are increasingly go- ing into private medicine in addition to the much healthier social classes I and II covered before. Secondly, there may have been an unexpected demand from taking on longstanding medical conditions, often contrary to normal insurance practice, when the bulk schemes were started; and thirdly, there may be fees submitted by a small group of unscrupulous specialists and foreign-owned private hospitals. I have knowledge of one case where the submitted fees of £15,000 were only reduced to a reasonable £8,000 when the patient pro- tested; I do not suppose this scale of over- charging is unique.
One hopes, none too optimistically, that all this is being sorted out, but the days are clearly long past when full private medical cover for a family could be bought for the price of 20 cigarettes weekly. In short, this country's private medical insurers have pro- bably come up against the same situation as in the US, with costs and therefore premiums rising rapidly and quite out of their control.
It provokes an interesting question what part should insurance play in personal health care for the good not only of the in- dividual but of society as a whole? Modern medicine for all its faults is not unreasonably expensive and few people could possibly hope to pay for it out of tax-
ed income, so some kind of insurance is essential. Insurance is, after all, a way of passing on the cost of misfortune to the community in general, but is it wise that the whole of this cost should be passed on?
What BUPA may also now be learning is that as soon as insurance is available people take advantage of it, and adopt a quite dif- ferent attitude to their illnesses and ac- cidents if somebody else is paying: there is good reason to feel increasingly uneasy about the amorality engendered by in- surance for health care. However one is in- sured, whether privately or through a state scheme, one does have an obligation not to take unfair advantage of the insurance agency, for example by staying off work for longer than is necessary. Unfortunately a very casual attitude towards expense in the private health sector is already clear, sometimes on the part of doctors as well as patients. One should be under no illusions about this, for while reasonable modern medical technology is expensive, the finan- cial irresponsibility and ignorance of some doctors are making things much worse.
Modern medicine, however, has been able to be extra expensive because insurance is picking up the bill; without insurance, unreasonable medical fees become impossi- ble through lack of money to pay them.
How to change things is another matter. Intelligence and aptitude tests for drivers would seem a good start; excess charges for private health insurance, and some kind of proportionate payment for NHS medical care, would encourage a sense of personal responsibility for health. Collection of money for every item of health care, though it works elsewhere, is such a hot potato that it would probably not be allowed by anything short of the complete financial collapse of the NHS. It may be very hard for the more liberal-minded to accept that insurance can encourage irresponsibility, though it won't be news to the insurance companies. That state support allows peo- ple to stay off work longer after accidents than is necessary, for example, may be the acceptable price we pay so that the rest can be ill in a dignified way and recover first before returning to work. But it is at least debatable that some payment, however symbolic and 'not worth collecting', might prevent some abuse of the system, and worst of all the tolerance of that abuse. It is this tolerance, though quite unmeasurable, that is itself in some ways the most depress- ing effect of the uneasy relationship bet- ween illness, disability and insurance.
All these arguments were, of course, trailed around before the 1947 National In- surance Acts; how ironic that, though used ineffectively by the Tory backwoodsmen against state social security, they should now be seen to have at least some validity in the private sector.
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