Adam Smith told me the invisible hand would protect me. Health insurance companies would enter the competitive marketplace and I would be offered choices. Consumer choice within the market would keep premiums low and services easily obtained. If I felt my rates were too high or the services offered too limited; I could exercise my market freedoms and take my business elsewhere, adding my weight to the invisible hand guiding the markets.
Secure in this knowledge, I was befuddled by the suppressed guffaw I received from the HR person at work when I stated I was unhappy with my current health care insurer and would like to see what other options the market currently offered. Not only did I have no choice other than the one the company had made on my behalf, but they were sorry to say that rates would again be increasing with the new fiscal year. On the upside, there was a new “Wellness Plan,” being offered that could lower my rate. To enroll I simply needed to complete a “Health Risk Assessment.” Adam Smith was now telling me to bend over, and I could hear him sliding a glove onto his invisible hand.
All the above was obvious and nothing you don’t already know and lose sleep over. The evils of a for profit health insurance system have always been in plain sight, but the right has done outstanding work convincing folk that “single-payer” or “socialized medicine” is the beginning of the end of everything.
Of course, insurance companies would prefer not to insure any sick people, but then people call them names and the government is forced to legislate something. But what if there was a way to exclude people that you knew would get sick in the future. Sure, take their premiums during the healthy decades, but have something stashed in the files that could be used to drop their sick butts when the time came to provide coverage. But again, the government gets prickly when insurers start demanding individual medical data for group coverage.
But what if it’s not the evil intrusion of a for profit insurance company? What if it’s the sincere concern of the “Wellness” division (of the evil, for profit insurance company)? A series of questions regarding you and your family’s medical history isn’t being asked to define you as high risk for future exclusion – it’s a wellness Health Risk Assessment. Answering these questions (voluntarily) enrolls you in a fabulous program being offered to you at no charge, that will help you to lose weight, sleep better, regrow your hair, enjoy everyday tasks and be the sexual dynamo you aways knew you should have been. There may even be company wide contests with tote bags! It’s how a giant corporation shows its love.
Not bad. A faux wellness incursion could amass an insurer a significant amount of data that could be used for future denials of treatment, but private medical information can only get a company so far, it’s not like having a copy of their genome… and it’s not like people have some way of getting their DNA sequenced, and even if they did, it’s not like they’d just leave it in the hands of some (DTC) third party to keep secure. And even if they did all that, surely the government would prevent an insurer from accessing such private data that could be used to deny coverage based on a single allele.
But people can get it – Ancestry, 23&Me. And they do leave it – unless they read the User Agreement, third party sequencers can do a myriad of things with a customer’s results. And the government did – in 2008 the government passed the Genetic Nondiscrimination in Health Insurance (GINA) law. Which made it illegal for an insurer to access or consider a person’s genetic information in connection with offering group health insurance. Mostly.
According to the CFR the law does list possible exceptions of inadvertent acquisition of a person’s genetic information – call them the oopsie caveats:
- Information overheard during a conversation
- Information received during a casual conversation, but no probing allowed
- Unsolicited email
- Through social media, if you’re friends
All of these seem based on the assumption that once someone at work knows your genetic details, the information will inevitably find its way to the insurer. Which is horrible, but horrible in a familiarly human kind of way – people ratting people out at work. Corporate horrible is a whole other level.
The other acceptable inadvertent acquisition of your genetic information according to GINA is when the information is obtained through a Wellness Program. And the gateway of any quality wellness program is the Health Risk Assessment (HRA). If I’ve been overly subtle up to this point, I’ll be more direct now.
A company that agrees to provide group medical insurance that is then administered through the company to its employees, has NO RIGHT to individual medical information. The HRA of a wellness program is nothing more than a covert attempt by an insurer to amass individual private medical information. Why? Because most laws governing insurers are focused on group healthcare policies, insurers are free to deny almost any type of private coverage. Look at the rates and availability of Long-Term care over the past decade or try to purchase private insurance without extensive medical screenings.
Why would anyone fall for this? First, most people do want to live a healthier lifestyle. Wellness programs employ psychological approaches that prey on common areas of self-reproach and promise all kinds of joy. It’s also convenient, right there on the company website. But the most successful tactic employed is money. Sometimes a direct reduction of a premium for attaining a wellness goal, or more insidious; a rate reduction for everyone in return for X% enrollment (with completion of the HRA). Economic combined with peer pressure; get healthier and don’t let the team down.
In law these are called inducements and GINA forbids the use of them in return for medical information. Mostly. But they may be offered for the completion of an HRA – if it is made clear that the participant is not required to answer questions of family medical history regarding genetic information. Simple enough to write a one hundred question HRA strewn with questions designed to reveal familial genetic information if you tell the respondent they can skip those questions.
In 2008 it was unclear how GINA settled the question of inducements, but the 2016 CFR made it clear; 30% of the cost of an individual premium was allowed. A married couple, insured through the same program but unwilling to complete an HRA could see a 60% higher premium than co-workers. By 2018 the AARP had successfully challenged that view, and today direct inducements are disallowed, but the committee is clear that the issue will be revisited.
This is a uniquely American issue. In societies with a single-payer system, the issue of privacy isn’t a concern to anyone – it’s an American reaction to worry that your health insurance company might get access to your health information. Tell your doctor everything – tell your insurer nothing.
Modern insurance corporations are judged by profitability, not the health of those insured. They compete in a marketplace unlike the one envisioned by Adam Smith. In the American system, abuses of the public interest by corporations in search of profits are mitigated through regulation. Regulation comes from public demand expressed through democratic processes. Another word for that is voting.