When healthcare reformers talk about making health insurance fair, some suggest that people who don’t take care of themselves really shouldn’t expect the rest of us to pay for their folly. They point to a study published in 2002 showing that, each year, the average smoker needs an extra $230 worth of inpatient and ambulatory care. “Problem drinkers” require an additional $150; obesity adds $395 to the annual bill, while simply being overweight costs an average of $125 a year. (According to researchers about one in three Americans are overweight while in one in five is obese).
Asking those who puruse less-than-healthy lifestyles to pay higher healthcare premiums seems, on the face of it, a simple matter of equity. But one needs to ask: what will be the effect? And where do we draw the line?
Some states already make smokers pay more. West Virginia, Georgia, Kentucky and Alabama charge state employees who smoke a surcharge on their health insurance. In Georgia, for example, those with a taste for tobacco pay an extra $40 a month. Meanwhile, in the private sector, Clarian Health, an Indianapolis-based hospital system, recently announced that starting in 2009, it will fine employees $10 per paycheck if their body mass index (BMI) is over 30. If their cholesterol, blood pressure, and glucose levels are too high, they’ll be charged $5 for each standard they don’t meet. And if they smoke, they’ll be charged another $5 in each check. This means that some employees stand to lose as much as $30 per paycheck.
Other employers take a more positive approach, offering discounts to patients who meet certain cholesterol, blood pressure, and BMI level benchmarks. But in economic terms, there is little difference between positive and negative reinforcement: if slim non-smokers pay less, other workers must pay more for there to be enough money in the pool to cover all employees. (This assumes that despite higher premiums, smokers go on smoking, drinkers continue to drink and the overweight don’t suddenly shed the extra pounds. In theory, financial incentives would motivate employees to kick all of their bad habits, but as anyone who has ever quit smoking knows, breaking an addiction is not as easy as it sounds. As for losing thirty or forty pounds —how many people do you know who are able to take it off and keep it off? You have to really, really want to do it, and even then, many fail.)
Nevertheless, even if financial incentives don’t change behavior, the whole idea of tying premiums to an individual’s habits appears to be gaining momentum. Earlier this year, the Department of Labor said that employers could use financial incentives to encourage workers to get healthy. And 62% percent of executives responding to a PricewaterhouseCoopers survey this spring said workers who smoke or are obese should pay for higher benefit costs, up from 48% in 2005.
Indeed some say that employers should go further in penalizing unhealthy habits. ”What about meat-eaters?” vegetarians ask. According to the Vegetarian Times meat consumption “costs Americans more than $60 billion, racked up annually in treatment for heart disease, obesity, cancer and food poisoning–making meat consumption more costly than the $50 million attributed to smoking. In light of this information–released in a recent study—-you would think the insurance industry would reward vegetarians for their lower rates of heart disease, cancer, diabetes, obesity and food poisoning with reduced premiums just as they do non-smokers. Unfortunately, these reforms won’t happen soon," the Vegetarian Times lamented. And the paper was right: the article was published in 1996.
But the vegetarians have a point. Since 1996, the evidence has mounted that those who eat a well-balanced vegetarian diet are less likely to die from ischemic heart disease. They also enjoy lower blood cholesterol levels and lower blood pressure, as well as lower rates of hypertension, type 2 diabetes, prostate and colon cancer. Recognizing the science, one forward-looking life insurance company in the U.K now gives vegetarians a 6 percent discount.
So why don’t we ask omnivores to pay more for health insurance? Because, while many of us view smoking, excessive drinking, and eating too much while exercising too little with great disapproval, we’re not as hard on meat-eaters. Perhaps it’s part of our Puritan tradition; at some level we associate tobacco, alcohol and excess body fat with “sin.” Eating meat on the other hand, is, a red-blooded American tradition. Even if we know, intellectually, that red meat probably isn’t good for us, not many people want to punish the omnivores. It’s okay to be rude to a smoker, but if an animal-loving vegan finds the sight of someone wolfing down a bloody steak disgusting, she is expected to keep her opinion to herself.
But wait a minute- are we talking about distributing healthcare costs more equitably, or are we talking about punishing sinners? And aren’t alcoholism, addiction to tobacco and obesity diseases? Not everyone agrees on this point, but the Academy of Family Physicians is clear: “Addiction to substances . . . is recognized as a chronic relapsing disease.”
Categorizing obesity as a disease is even more controversial, but medical evidence shows that there is a genetic component to the problem. “Studies of twins indicate that about 50% to 70% of the tendency toward obesity is inherited. Likewise, studies show that when both parents are obese, the chance their offspring also will be obese is 60% to 80%. In contrast, when both parents are thin, the likelihood of a child becoming obese is 9%.
Moreover, the Center for Disease Control points out, some of us put on fat more easily—and have a harder time losing it—even when eating no more, and exercising no less, than others: “In an environment made constant for food intake and physical activity, individuals respond differently. Some people store more energy as fat in an environment of excess; others lose less fat in an environment of scarcity. The different responses are largely due to genetic variation between individuals.” This may help explain “why . . . interventions based on diet and exercise [are] more effective for some people than others.”
If we demand that smokers, drinkers and the obese pay higher insurance premiums, we are, in effect, punishing them for being sick– while ignoring the fact these problems are extraordinarily hard to beat. A financial penalty probably won’t bring an end to an alcoholic’s hankering for liquor, though it may well make him angry enough to drink more. Those who believe that hiking premiums can change behavior tend to assume that with just a little will power, anyone can break an addiction—or lose weight. Experts who work with patients suffering from these problems know better.
Successful weight loss — losing weight and keeping it off — is so unusual that University of Colorado Professor James Hill keeps a list of people who have managed to do it. After studying the 3,000 people in the National Weight Control Registry, Hill and his colleagues have discovered that only five percent of dieters actually keep the weight off. The group has come up with seven keys to losing weight: Their first tip: “Expect failure, but keep trying.”
Quitting smoking seems easier, judging by the number of Americans who have managed to kick the habit. But again, it’s not clear that financial penalties are the answer. Granted, higher cigarette taxes do have an effect:, especially on kids: every 10 percent increase in the real price of cigarettes seems to reduce the number of kids who smoke by 6 percent to 7 percent while cutting overall cigarette consumption by 3 to 5 percent. Yet, despite ever-higher taxes on tobacco, nearly 50 million Americans still smoke. As for alcoholism, Alcoholics Anonymous tells us, this is a condition that can never be cured. A drinker will always be a "recovering alcoholic."
Finally, everything we now know about obesity reveals that it is a surprisingly complicated problem. While it might seem that eating is a matter of choice, in fact there is a complex biologic system that controls food intake and can make it very difficult to lose weight according to Dr. Arthur Frank, medical director of the George Washington University weight management program and Glenn A. Gaesser, director of the kinesiology program at the University of Virginia. Writing in OB/GYN News they point to studies suggesting “that there are at least 40 to 50 difference substances—including hormones, neurochemicals, and gastrointestinal peptides, that regulate eating and body weight. This complex system of eating and weight control breaks down spontaneously in some people . . . To say that being overweight is a result of only poor choices makes little practical sense. Advising an overweight patient to eat less and exercise more is like telling depressed patients to pull themselves together or an asthmatic to breathe easier.”
In the end, it is not at all clear that higher insurance premiums for those who smoke, drink or are significantly overweight is likely to improve the overall health of the population. Instead, hiking premium only makes it more likely that people who most need to see a doctor will go without insurance. In the long run, that means that we all will have pay more to treat the lung cancer, heart disease or cirrhosis of the liver that might have been caught earlier.
Finally, it’s worth keeping in mind that insurance is designed to let the lucky provide a safety net for the unlucky. You hope never to use your fire insurance. Yet you buy it, knowing that if you need it, you will be happy you had it. If you don’t ever need it, you will be even happier to let your premiums help someone else who lost his home.
When it comes to health, the fortunate include those who never started smoking because they just didn’t like the taste or the smell. They are luckier than those of us who become addicted to nicotine and later had to go through the agony of quitting. (Or didn’t quit, and still endure the guilt that most smokers feel). Then there are those who, thanks in part to genetics, seem able to eat whatever they what—without gaining weight. Finally, consider the many people who enjoy wine with a meal, or a beer at a ball game, but virtually never drink too much. Others cannot have one drink without wanting five. AA tells us that at best, alcoholics can train themselves to stay away from liquor altogether. They just are not as lucky as those who can enjoy a glass of wine with a meal .