Eat, drink and be merry...

For tomorrow you may pay the penalty

A few days ago a friend said that she thought people who have

unhealthy life styles should not have their medical costs covered by insurance. Health insurance rates are sky-high, and it is unfair that people who live healthily have to pay for other people’s bad choices. While I see her point, loud inner voices were clamoring against this point of view, so I decided to check out some of the facts and look into the arguments for punitive measures and against them.

The facts are indeed shocking. Something like 20% of US health care costs are spent on obesity-related problems. Alcohol abuse costs the US economy more than $200 billion a year. Tobacco, drug addiction and risky behavior all take a toll as well, although smokers in the US apparently pay higher health insurance rates than do non-smokers.

Most of these costs are paid for by society, not only in high insurance premiums but also government health care and disability benefits. These are only the direct costs, with time lost from work, prevention campaigns etc. also adding up to hefty indirect expenditures.

In favor:

In light of these figures, it is understandable that there are several arguments in favor of making people with unhealthy life styles pay the costs of their choices. Lowering tariffs for the rest of the population is the most obvious. In addition, one argument goes, knowing that they would be out of pocket were they to end up in the doctor’s office or in hospital would have a motivating effect on getting these people to live more healthily. Most often encountered is the argument for moral individual responsibility. These people living carelessly are doing something wrong and they should pay for it.

Against:

There are, surprisingly, more arguments on the other side, i.e. that

everybody should be treated equally. Solidarity, for example, which is of course the philosophy behind insurance. Then there is the question of people who are addicted, who cannot be said to be choosing an unhealthy lifestyle, as do people engaging in risky sports, for example. From the practical point of view, people who give up unhealthy behaviors will probably live longer, thus costing society more in the long run when they reach old age.

Social inequality is cited as a reason against making people pay the costs of their unhealthy choices, for such costs would bite far more heavily into the budgets of the poor than of the rich. This argument is applied to the effect of indirect penalties such as higher cigarette taxes as well. Addicts barely managing financially will have to choose between their drug and having enough food, for example. For an addict, it is unlikely that higher taxes will have the desired effect, in any case.

From the purely practical point of view, it is often impossible to

prove that a particular individual’s medical problem stems from bad lifestyle choices. One envisions doctors having to make difficult judgment calls and court cases as a result, perhaps leading to the setting of arbitrary limits, for example the number of cigarettes smoked per day that divide the good from the bad. “Health police” would be a part of our vocabulary.

In thinking about “lifestyle choices” one sees a difference between those that are unhealthy and those that are risky. For someone in the ICU with concussion and multiple fractures after a parachuting accident, cause and effect are pretty obvious. But should parachuting therefore be classified as “risky behavior”? Boxing? Playing football or ice hockey? Bungee jumping? Even here categorization is difficult and would end up being judgmental.

It is perhaps just the judgmental, moralistic and socially unfair attitudes that rub us the wrong way. Insurance, based on solidarity, has been around for a long time and enjoys widespread acceptance. Perhaps we have to realize that those who live riskily or unhealthily are apt to suffer physically, mentally and emotionally at some point from their lifestyles, and that is punishment enough.