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Health care ethics question

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I am curious what people think about this:  Is it morally permissible to charge higher health insurance premiums to people that smoke or, more controversially, people that are overweight?  Might we even say that we ought to do that (not just that it would be permissible)?  I read last week that 50% of our health care expenses are avoidable since they stem from smoking, poor fitness, and obesity.

Thoughts?

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11 Comments

  1. Jon says:

    I’m not totally unsympathetic to so-called “sin taxes,” but I have a couple of concerns.

    First, where do we draw the line? Charging people who smoke and are overweight seems straightforward enough, but do we also penalize people who, say, eat fast food?

    The second (and primary) concern of mine is that such taxes are terribly regressive–that is, they adversely affect the poor. A healthy diet and regular exercise are luxuries that not everyone can afford. Obesity is most rampant among lower classes, because the cheapest and most convenient food is often the least expensive (fast food, junk food, etc.). Poor health habits like excessive drinking and smoking are also disproportionately found among lower classes. I’m against hiking these peoples premiums, because these are the same people who are already struggling to acquire/afford health care.

    I’d prefer a system whereby health behaviors are incentivized, but poor behaviors aren’t penalized per se.

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  2. Kleiner says:

    I am not as worried about a slippery slope. Smoking and being overweight are easily measurable and have measurable health effects. Eating fast food, by itself, does not have immediate health effects and does not increase your costs (if you are otherwise fit and lean, a McDoubleFatty every once in a while is not a problem).

    I am much more sympathetic with your second concern (more so with the healthy diet point since regular exercise is free – people just need to choose to do it). In fact, this is about the only argument that gives me pause.

    The idea to incentivize good behavior without punishing bad is a nice idea, in principle, but I don’t see how it really changes the math. If you incentivize being lean and fit, probably by giving a rebate, then you come up shortfall in revenue to pay for the total costs of care for all insured. How to handle that? If you are talking private insurance, insurance companies will either (a) cut their profits (unlikely) or (b) pass that extra expense on to consumers (resulting in higher rates for the overweight poor). If it is a govt “public option” program, will we make up that shortfall by taxing other people (say, the rich) in order to subsidize what is a largely a behavior-induced health epidemic? Point is, someone will get penalized once you incentivize a certain behavior – who pays? Is it just to make A pay for B’s expensive behaviors?
    Regarding questions like this, I end up having a battle between an inner libertarian on one hand and my Christian social morality on the other (yes, you ARE your brother’s keeper).

    There are other programs one could consider, aside from the rather blunt insurance premium hike plan. To avoid ‘robbing Peter to pay Paul’, we might have a soda tax (Obama has considered this). While it might be the case that the poor drink more soda than the wealthy (I don’t know if that is true), such a sin tax does not seem particularly predatory because clean drinking water is available almost everywhere in this country. This would raise money and disincentivize one major obesity cause.

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  3. Huenemann says:

    I have concerns similar to Jon’s. With cigarettes and fast food, we have industries aimed at making products that are highly addictive and as cheap and as readily available as possible. We could add gambling in here, too — all prey on those who have weak wills or are just foolish. If we place higher taxes on the abusers, or additional insurance costs, we’re further hurting a population that already is down in one or two respects.

    But I wouldn’t want to ban the products, since a burger and smoke while scratching off a lottery ticket can be a sporting good time. I wonder if the producers, who are making large profits off their weak-willed, foolish victims, ought to pay something to offset the harm they help people to do to themselves. True, they would probably just pass this cost along to their consumers, but that might further encourage those who can’t afford it not to do it.

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  4. Kleiner says:

    We all share the same concern.
    My suggestion was sin taxes (soda taxes, etc). Huenemann suggested we tax the producers to offset the health care costs of their products. I am not particularly opposed to that, but as Huenemann notes the producers would just pass this extra cost on to the consumer in the form of higher prices.
    Assuming that, I don’t see how this suggestion (or my sin tax suggestion) is all that much different than raising health care premiums. Both options are paternalistic as they seek to shape citizen behavior by hitting them in the pocketbook. (I am rather sympathetic to “soft paternalism” like this, so I am not particularly bothered by that). More to the point, in both cases you are increasing the cost of living for the smoking/obese poor. I suppose the latter is a more blunt instrument (you are increasing cost of living in one big chunk instead of a more incremental cost of living increase as a person buys smokes or eats hamburgers over the course of a year).
    It might just be that paternalistic policies (increasing the cost of unhealthy choices for consumers) will hit the poor harder, but that there really is no other way to do what must be done (which is change American eating, fitness, and smoking habits).

    To be devil’s advocate: It is the case that there are higher rates of obesity among the poor. But is it because of what Jon says? “A healthy diet and regular exercise are luxuries that not everyone can afford. Obesity is most rampant among lower classes, because the cheapest and most convenient food is often the least expensive (fast food, junk food, etc.)”
    Is it true that healthy foods are a “luxury” and that cheap and convenient foods are less expensive? When I take my family of 4 out to McDonalds, it can easily cost $20. But I only spend $70 or so a week on groceries (bkst, lunch and dinner). Canned vegetables are very cheap. A bag of rice or beans costs next to nothing. You can get a pound of ground beef for less than $2. As for convenience, while there is no doubt that processed/boxed foods are more convenient, they are also more expensive (it is always more expensive to buy a “boxed food” than it is to make it yourself). Need a crunchy snack? I could buy 2 pounds of carrots for the price of 1 bag of doritos. Thirsty? A gallon of tap water costs about 1 cent per gallon. 2 liters of soda (about 1/2 gallon) costs, what, $4? (I don’t drink soda, never buy it, so have no idea how much a 2 liter costs).
    Point is, Jon’s causal claim is far from obviously true. Perhaps the urban poor do not have access to fully-stocked grocery stores but instead shop at corner convenience markets (who carry mostly unhealthy food). But I don’t see that this is necessarily the case either – I’ve lived in urban areas (Chicago, Indianpolis, and the poor urban area of Boston called “Southie”) and I had no trouble getting to big mart grocery stores (and in two of those cities I was living without a car).
    I am inclined to identify a different cause – a cultural one. For instance: obesity is highest in the south. Why? This is not because southerners don’t have access to or cannot afford healthier choices. Rather, it is because of their “food culture” – a culture which sprung out of a history of poverty. Some time back, frying everything and cooking in lard was necessary as it was the cheapest way to get protein. Sure it was fattening, but most worked manual labor jobs so burned more than enough calories working. But now protein is very cheap (pound of ground beef for less than $2 a pound, chicken for even less), though the southern food culture has not adapted to the changing food availability. So people still cook old fashioned southern meals even though they get way more protein and fat in their diet than they would need, particularly because most are not working manual agri-labor jobs any longer.

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  5. Kleiner says:

    Interesting. But I wonder two things:

    a) Did they price fresh or canned fruits/vegetables? Dried black beans are really cheap, so is rice as are most canned vegetables.

    b) I am not sure a “calorie to calorie” comparison is the best measure. I think a better measure (though not as easily quantified) is some kind of a “fullness measure”. How much junk food do you need to eat in order to “feel full” (and not crave food 1 hour later) as compared to how much healthy food you would need to eat to “feel full”?
    A study done (I read about it a few years ago in the South Beach Diet book) showed that people that ate “energy dense” but junk (highly processed) breakfast food ended up eating 3 times more calories between bkst and lunch as compared to those that ate a healthy breakfast. In other words, despite the higher calories they felt hungrier and so ate more. This is anecdotal, but we all know you feel hungry an hour after binging on a whole bag of chips. Those junk calories (sodas, candy bars, chips, highly processed grains, anything with high fructose corn syrup, etc) might be cheaper by the calorie, but they are much more expensive when measured in terms of the cost to satisfy the “perceived need” (feeling full).
    And we all have the anecdotal evidence that you suggested (living for a week on 10 or 20 bucks on pretty healthy foods).

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  6. Jon says:

    “For instance: obesity is highest in the south. Why?”

    Sure, Southern food culture has explanatory power. But it’s also true (and I think more important) that the South has the highest rates of and most persistent poverty.

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    • Kleiner says:

      Fair enough. I rather suspect that there are multiple causes. So, to quote Dr. Katz, “It is not so much that I am disagreeing with what you said as much as I am agreeing with what I said.”

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  7. Clay says:

    “Is it morally permissible to charge higher health insurance premiums to people that smoke or, more controversially, people that are overweight?”

    I suppose it comes down to risk for the company. Insuring a fat smoker is a bigger risk than an avid marathon runner. Insurance companies operate in much the same way that banks do. They are both setup around risk.

    Banks reward a customer’s good behavior by offering him a better loan for his financial sense.

    Allowing insurance companies to charge fat smokers more will create an incentive for those fat smokers to become more health conscience.

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  8. shaunmiller says:

    Soda is relatively cheap. It’s about $1 for 2 liters. But the main reason it’s cheap is because of the corn syrup which the government has subsidized for the past 50 years. Indeed, corn syrup is in pretty much everything and that might help explain the obesity epidemic. Perhaps instead of the government being involved in solving the health problem, why not stop subsidizing corn? Doesn’t anyone find it odd that an apple is roughly the same price as soda? A box of surgery cereal is about the same price as a box of rice? And that chips are roughly the same price as a gallon of milk? Perhaps the government should get to the source of the problem and stop subsidizing corn. That way, the market will realign itself, people will probably not buy soda and other junk food that much because it’d be so expensive, and we’d be healthier for it.

    I’ve only given this a little thought, but it seems that the major problem about the health of America never really gets to the source.

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