dictable illness. That is why we are willing to help pay for others' misfortunes and consider ourselves fortunate if others do not have to pay for ours. When health insurance is extended to cover costs that are the likely or certain outcome of willful choices, not only are the costs of insurance raised for all of us, but its moral and psychological support is undermined. When insurance is used to pay for occasional checkups, for the normal, routine ailments that all of us can expect to experience from time to time, that are not expensive and that in many cases do not really require medical care, it is no longer insurance, but prepayment. But, unfortunately, insurance seems headed toward more coverage of behavioral illness and of normal and routine medical care.
What matters most is not the coverage of individuals--universal coverage eventually--but the coverage of procedures, especially surgery, and of tests and drugs. There are two issues here: which procedures and tests are covered, which are not; and to whom is the coverage extended, and for what purposes. Coronary bypasses, caesarean sections, and appendectomies are all covered, but it is clear that too many are performed. What criteria should be met if they are to be reimbursed? For example, blockage of three arteries justifies bypass surgery, but blockage of only one does not, unless it is the left main coronary artery. The condition of the patient must also be a consideration. Existing technologies--psychoactive or psychotherapeutic drugs, the area of addiction generally--are subject to almost indefinite expansion as concepts of unacceptable or undesired behavior and of addiction expand and are redefined as illness (see Chapter 7). Today, nicotine addiction is an officially recognized psychotherapeutic disorder; tomorrow? New and future technologies open up a Pandora's box in terms of who is covered: genetic testing, genetic therapy. Decisions on what procedures and which individuals will be covered by insurance could add hundreds of billions to our annual health care bill.