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Health Insurance Coverage Presented By The Notorious Nurses: Anne Dean, Tsion Berhanu, Shaneen Fernandez, Rebecca Khim, Carrie Phillips & Andrea Zipperer Health Care Insurance Coverage for Self-Influenced Illness Alcoholism, Obesity, Smoking Coverage vs. Claim Pre-existing Conditions

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Health insurance coverage l.jpg

Health Insurance Coverage

Presented By The Notorious Nurses:

Anne Dean, Tsion Berhanu,

Shaneen Fernandez, Rebecca Khim,

Carrie Phillips & Andrea Zipperer



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Coverage vs. Claim

  • Pre-existing Conditions


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Four Options

  • No Coverage whatsoever

  • Coverage but not claims

  • Coverage regardless (includes all claims)

  • Coverage including initial claims when accompanied with behavior changes


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Health Insurance Denial for Self-influenced Health Problems

  • Self-influenced health problems

  • Impact on healthcare costs/insurance rates


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Ethical basis for denying coverage

  • Economic benefits

  • Consumer Benefits

  • Insurance company profits


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Promote independence and self accountability for health

  • Health Promotion/Illness Prevention

  • Price sensitivity

  • Reduce self-influenced health problems


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Measures to counteract health insurance coverage denial

  • Alternatives: smoking cessation programs, government action and public persuasion to combat obesity, alcohol use, and smoking

  • Lifestyle changes: weight loss, physical activity, smoking cessation, and reduced alcohol consumption

  • Alternative solutions—“minimize the effects of self-influenced health problems while also reducing health insurance rates” (allieduotes, insure.com)


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Denial of Insurance Coverage Claim by Claim

  • Individual responsibility & choice

  • Self-influenced health behaviors

  • Increased health hazards yields increase in health costs



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Is Healthcare coverage a right or a privilege? States,1997–2001

  • Equal access to healthcare

  • Equal quality of care

  • Equal price of coverage


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Consequences of unequal coverage States,1997–2001

  • Millions of men, women and children have no health coverage

  • People without healthcare coverage find themselves in thousands of dollars of debt with medical bills

  • Medical debt accounts for over half of all personal bankruptcies


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Diseases of addiction: Smoking States,1997–2001

  • Nicotine’s chemical structure is similar to the neurotransmitter acetylcholine

  • Within eight seconds of the inhaled puff of smoke, nicotine arrives at the brain causing release of dopamine

  • The brain adapts to the new effects of the chemical and an absence can lead to severe mood swings and anxiety


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Diseases of addiction: Alcoholism States,1997–2001

  • Three of the most important NTs with respect to alcohol are:

    • Glutamate (inhibited)

    • Serotonin

    • Dopamine

  • Reward center of the brain


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Diseases of addiction: Obesity States,1997–2001

  • Mental Health

  • Eating disorders

    • Bingeing (compulsively overeat)

    • Bulimia Nervosa (binge and purge)

  • Sugar bingeing produces dopamine in the brain

  • Research is currently underway to determine if food additives are addictive


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Equal health insurance States,1997–2001

  • Smoking, alcoholism and obesity should be in the same category as depression and cancer


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Health Insurance companies have the option of providing coverage for everyone, but,

  • Limiting that coverage after a modifiable disease factor is identified

  • Health Insurance companies would also help pay for the treatment necessary to change the modifiable disease factor

  • The insured must be willing to actively change their behavior to reduce the cost risk to the health insurance company


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This is not an easy issue to side on, especially from a nursing perspective

  • Insuring individuals who participate in these behaviors is extremely costly, and that cost is often dispersed among all insured, raising the cost for those individuals who have healthy lifestyles.

  • This leads to many people not being able to afford insurance. One might also argue that there is little incentive for those individuals to change their life styles if they know that a tertiary solution is on the horizon.

  • “Why should I try to change my diet when I can just get that new stomach surgery and my appetite will just decrease automatically?”


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The other side of the issue poses the question: nursing perspective

  • Do we really want people dying because they have fallen victim to the addictions of society?

  • Tobacco and alcohol are indisputably addictive substances and for many, eating can also be an addictive behavior.


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Four Options: nursing perspective

  • Denying coverage for any individual who has a high-risk life style

  • Providing coverage for all, but denying any claim that relates to a lifestyle factor

  • Paying for the initial cost of rehabilitation for that client, but denying claims in the future

  • Providing coverage for all, regardless of lifestyle


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The common thread throughout the exploration of this issue is the role that we as nurses can play, including:

  • Lowering health care costs through health promotion and illness prevention

  • Improving the health of those who will potentially suffer from the consequences of their lifestyle decisions through our power to provide illness prevention and health promotion


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Resources is the role that we as nurses can play,

  • Achman, L., & Chollet, D. (2001). Insuring the Uninsurable: An Overview of State High-Risk Health Insurance Pools.Retrieved November 5, 2008, http://mathematica-mpr.com/publications/PDFs/uninsured.pdf.

  • Alliedquotes (www.alliedquotes.com/resources/health-insurance-rates.html)

  • Center for Disease Control (www.cdc.gov). (http://www.cdc.gov/tobacco/quit_smoking/cessation/coverage/.htm).

  • Chitty, K.K., & Black, B.P. (2007). Professional Nursing: Concepts & Challenges (5thed). St. Louis, Saunders Elsevier.

  • Eating your way into the Hospital and the Poorhouse (2004, September 16). Retrieved October 13, 2008, from http://www.insurance.com/article.aspx/Eating_your_way_into_the_hospital_and_the_poorhouse_/artid/72.

  • Edelman, C. L., & Mandle, C. L. (2006). Health Promotion: Throughout the Life Span (6th ed.). St. Louis, Missouri: Elsevier Mosby.

  • Health Insurance 360 (http://www.healthquote360.com/individual_health_insurance/health_insurance_for_pre-existing_conditions.php) 

  • HealthPac online a vision of quality healthcare for all (http://www.healthpaconline.net/health-care-insurance.htm).

  • Huether, S. E., McCance, K. L. (2008). Understanding Pathophysiology (4th ed.). St.Louis: Mosby Elsevier.

  • Insure.com (www.insure.com/articles/healthinsurance/weight.html).

  •  Food and Addiction (http://www.yaleruddcenter.org/reports/pdfs/RuddCenterAddictionMeeting.pdf)

  • Sturm, R. (2002). The Effects of Obesity, Smoking, and Drinking on Medical Problems

  • and Costs. Health Affairs. Retrieved November 5, 2008, http://content.healthaffairs.org/

  • Alcohol Chemistry & You (http://chemcases.com/alcohol/alc-07.htm#Once%20inside)

  • Sturm, R., Ringel, J. S., and Andreyeva, T. (2004). Increasing Obesity Rates And Disability Trends. Health Affairs. Retrieved November 5, 2008, http://content.healthaffairs.org/

  •  Why Quit.com (http://whyquit.com/whyquit/LinksAAddiction.html)

  • USAToday. (http://www.usatoday.com/money/workplace/2006-02-16-smokers-cost-more_x.htm)


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