Altruism and coverage of the uninsured.

Al-tru-ism. 1: unselfish regard for or devotion to the welfare of others. 2: behavior by an animal that is not beneficial to or may be harmful to itself but that benefits others of its species.1 The article in this month's Journal of General Internal Medicine by Goold et al.2 reports their study of the possible role of altruism in providing health insurance coverage to the uninsured. Such an approach is a novel one among the current efforts to improve access to care. President Bush's initiatives to improve health care access involve helping people pay for insurance (health savings accounts, tax credits, and deductions), decreasing the cost of insurance for small businesses (association health plans), and decreasing health care costs (medical liability reform).3 Senator Frist's recently released task force report on health care access also targets market-based reforms to decrease costs (liability reform, improving technology, and reducing unnecessary regulations and red tape), increase coverage (tax credits, new insurance plans and pooling options, and optimize public programs), and improve the safety net (add community heath centers and increase doctor participation).4 Senator John Kerry proposes to decrease costs (reimbursement for catastrophic costs, reduce prescription drug and malpractice costs, reward quality care, and use technology to cut administrative costs), expand government programs for children and the poor, and allow the public to buy the same insurance as members of Congress.5 Physicians for a National Health Program (PNHP) proposes a single-payer system that creates savings by eliminating the profit motive and sharply reducing administrative costs.6 The recent Cover the Uninsured Week (CTUW), sponsored by the Robert Wood Johnson Foundation and others, simply educated the public about the problem and effects of uninsurance, without advocating any specific proposal for change. Grassroots efforts, such as PNHP and CTUW, assume that dispelling myths about who is uninsured and educating about the effects of uninsurance on business, the insured, and communities will encourage health reform. While the study by Goold et al. did not include an educational component per se, its small group deliberative process resulted in de facto sharing of information about the uninsured and the effects of uninsurance. It also provides insight into the deliberative process that could inform grassroots efforts. The study found that, prior to group deliberations, about 50% of individuals were willing to give some of their health care dollars to cover the uninsured, especially children (22% covering adults and children, 32% just children). The group deliberation process, with its sense of community and discussion of the issues, resulted in 100% of groups allocating some portion of their money to cover the uninsured (76% covering adults and children, 24% children only). Notably, this altruistic spirit diminished substantially (but did not extinguish completely) when the groups disbanded, as just over 66% of individuals then allocated dollars to cover the uninsured (31% covering adults and children, 31% children only). Predictably, children—the most vulnerable and least “responsible” of the uninsured—were the group most likely to be covered by both individuals and groups. The study demographics limit the ability to extrapolate its results: all participants were white and insured, predominately female, and “largely middle class” Minnesotans. Despite these limitations, the findings are instructive and potentially more applicable in the real world than a simple questionnaire or poll because the study participants had to act on their opinion, albeit in a game-like setting. Analysis of the group conversations disclosed reasons that participants opted to provide coverage to the uninsured: (1) they themselves, or people they are close to, are or might become uninsured; (2) they want to care for a vulnerable population (especially children, the elderly, and their caretakers); and (3) it promotes the common good (keeps communities safer, people working, etc.). Conversely, the principal reason coverage was not extended by some participants was their view that it is not an entitlement but rather a personal responsibility that people could choose to obtain or not. Participants also voiced concern about “free riders” taking advantage of free coverage. Because there were “few demographic or attitudinal differences between individuals who did and did not allocate … to the uninsured,” this study does not help grassroots efforts to better target their efforts to specific demographic groups. Those who did not choose to cover the uninsured were more likely to have higher out-of-pocket health care costs and “to agree that the health care system is ‘broken.’” Perhaps coverage of the uninsured would result in a greater personal sacrifice for these individuals (higher out-of-pocket costs) than they were willing to make. Arguably, a system of progressive taxation to cover the uninsured rather than pure altruism might be more acceptable to these participants. These surprisingly positive study results indicate that there may be a hitherto unexplored place for altruism in the effort to cover the uninsured. (Simplistically, one imagines a box to check on heath insurance application forms allowing a donation to cover the uninsured each time a premium is paid). Although the time-intensive deliberative process employed in the study would be difficult to implement on a large scale, the study demonstrates the significant positive impact of group or community decision making on notions of distributive justice that grassroots efforts may wish to incorporate.