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January 25, 2006

Three Cheers For The Nanny State!

Ah, a chance to disagree with my health care ally Kate. In response to Tommy Thompson's totally awesome nanny state proposals (make employees with health care exercise, double the price of junkfood in employee cafeterias, charge smokers more for insurance, etc), she writes:

What is this, a police state? You can't require employees to exercise. Charging smokers more for insurance is quite a slippery slope. What's next, charging overweight people more? These kinds of punishments are all speculative -- is charging smokers more for insurance an incentive to quit anyways?

First off, this is a nanny state. Small, but important, difference. As for smokers, whether or not they quit isn't my problem. But a behavioral choice that essentially ensures catastrophic illness and shoots up total health costs*? Yeah man, charge them more, me less. And you can't require employees to exercise, but you can lower their premiums if they do.

This idea that we shouldn't be honest about the impact of the choices people make is nuts. The general slippery slope retort -- next you'll charge me for skiing! Not lifting from my legs! Touching my daughter without gloves! -- is nonsensical. We didn't invade every country with a dictatorship, despite rationalizing the Iraq War in a manner that would've mandated it and nor did we solve Social Security's fiscal crisis despite spending months hyping its severity. As a society, we're completely capable of laying down lines in issues tinged with logical ambiguities or argumentative absurdities. Sometimes we're right, sometimes we're wrong. But the way to analyze higher premiums for smokers or employer policies compelling exercise isn't what's next, but an analysis of those, now. I judge it good, others judge it bad, but let's have the argument on its own terms.

*There's some ambiguity about the total costs of smokers because, though they get sicker than non-smokers, they also die sooner.

January 25, 2006 | Permalink


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Can we also double premiums for all SUV drivers, given that they are also currently engaging in a behaviorial choice that essentially ensures catastrophic accidents and shoots up total health costs?

I mean, if we're going to have a nanny state, let's go after something useful.

Posted by: Brad Plumer | Jan 25, 2006 4:10:56 PM

The general slippery slope retort ... is nonsensical. ... As a society, we're completely capable of laying down lines in issues tinged with logical ambiguities or argumentative absurdities.

As far as I could parse here, you're saying "The argument that we have to behave consistently is belied by the facts; we frequently behave inconsistently." Is that right?

Made even more extreme, it sounds like "Even as armchair theorizers unconstrained by practical considerations, we shouldn't have to make decisions based on some kind of principles." Since I doubt that's really what you want to say, I'm looking for some clarification here.

Posted by: Allen K. | Jan 25, 2006 4:12:40 PM

Even without resorting to the slippery slopes, the rules under question are invitations to either fraud or privacy-diminishing measures to prevent it.

Posted by: djw | Jan 25, 2006 4:19:11 PM

Allen: . Our society has always been capable of drawing distinctions and deciding which lines of thought and theory it wanted to ride all the way out. And you're right, I don't think our actions should be dogmatically dictated by broad principles, I think, as I wrote, that we should evaluate specific policy proposals and make decisions.

Posted by: Ezra | Jan 25, 2006 4:24:01 PM

Whoa!! I thought the ideal liberal healthcare system was one of gov't paying the bill and no responsibility for the individual?

Hey, if you are now going to play this game, why not charge homosexuals more? It can certainly be proven that, as a risk group, they will cost more.

You can't have it both ways!

Posted by: Fred Jones | Jan 25, 2006 4:36:16 PM

Couple of problems here I see...

First, while I understand the proposed rationale for charging smokers higher premiums (as already happens with life insurance policies), what bothers me about it is its singling-out of a particular vice. Instead of a slippery slope issue, it's the opposite, where one group is penalized and its equivalent isn't. Why would smokers be penalized, but not active functional alcoholics, or presciption-med abusers, who may be doing as much long-term damage to their bodies, even if their vice is not as immediately evident? I've worked with plenty of alcohol- and drug-abusers whose problems weren't known by the boss (or, likely, the insurance provider), and would have been able to stay clean long enough to pass a blood test. Raising premiums just on smokers (while smoking is still legal) seems unfairly arbitrary.

As regards the weight issue, weight isn't always a perfect indicator of health. It's possible to be overweight but healthy, and it's possible to be thin as a rail and have sky-high cholesterol levels leaving you a heart attack waiting to happen.

Look, I'm overweight, but I'm healthy. I've got a good heart, good circulation, no diabetes, etc. My fat arse can trek 20 miles up- and downhill through the Highlands in a day with no problem (and, frustratingly, not lose a bloody pound). For someone like me, who might look unhealthy if you go by weight alone, the prospect of using a scale to determine my insurance payments is decidedly unthrilling. A better measure would be healthfulness, rather than simply weight itself. But once you start measuring people's blood pressure and cholesterol levels and all that stuff to measure healthfulness, then you really are onto a slippery slope argument.

Offering lower premiums to employees who exercise - fine. As long as the lower premiums are predicated only on the engagement of the regimen and not on some set of results that ignore not every body is the same.

Posted by: Shakespeare's Sister | Jan 25, 2006 4:43:18 PM

I don't really see how the fact that some vices are less obviously testable than smoking means we shouldn't go after the ones we can test. And we already do it all the time, through cig taxes. If some smokers find this unfair and arbitray and decide, in protest, to stop smoking, I'll cry no tears.

And does anyone else occasionally wonder if Fred, like Kevin Drum's Al, is really just a liberal creative type engaged in a long-running piece of performance art meant to mock a stereotypically inflated, ignorant, dittohead?

Posted by: Ezra | Jan 25, 2006 4:57:59 PM

How exactly does one require employees to excercise and prove that the employees are in fact doing so? Mandate that only the employer's on-site gym is an acceptable site for working out? Make employees get a card stamped every time they go to the health club? Use the 'buddy' system and force employees to excercise during lunch hour with at least one other employee who can vouch for their participation?

So much for jogging in the park, walking, biking, or even just doing an excercise video in one's living room.

Posted by: fiat lux | Jan 25, 2006 5:05:42 PM

I don't really see how the fact that some vices are less obviously testable than smoking means we shouldn't go after the ones we can test. And we already do it all the time, through cig taxes. If some smokers find this unfair and arbitray and decide, in protest, to stop smoking, I'll cry no tears.

But your whole rationale for raising the premiums on smokers was that other people shouldn't have to pay for the social costs imposed by people who smoke. In other words, you were making a fairness argument.

But then in the interests of fairness why should I, a smoker, have to pay the social costs imposed by people who engage in all sorts of other behavior -- car drivers, alcoholics, drug users, rock climbers, etc.? Essentially, you're singling out smoking because it's "unfair and arbitrary" that everyone else should have to subsidize the costs of that behavior, but applying the principle in -- shall we say -- an unfair and arbitrary way.

And no, I wouldn't be so opposed if I didn't smoke. Oh well. But djw's privacy concerns, above, are pretty legitimate.

Posted by: Brad Plumer | Jan 25, 2006 5:13:29 PM

Wow! I am shocked to here this from a progressive. You must be a young healthy guy. No health problem in your near future. I am all for trying to give incentives for
reducing risky behaviors. Insurance is about spreading risk not first trying to reduce it. Remember you will not be the one who can make all of the decisions about
what is covered and what isn't.

Posted by: rasscot | Jan 25, 2006 5:18:37 PM

Ezra, this is a slippery slope in regards to health care. Not all, but a great many diseases do have behavioral causes or associations (coincidence is not proof of causality). Saying that only those proven behavioral causes should be penalized is no refuge. Some smokers do live a long time and die of unrelated problems - for instance, diabetes.

The whole idea of risk pooling is to pool the risks, including everyone. When some people are taken out of the pool (or put in another pool), for whatever cause, then you have started back down the road to everyone for themselves health care. Age is a proven cause of death. Should those over 75 be thrown out of Medicare because their profile says they will cost more? Should 25 year olds with Type II diabetes (causation unclear at this time, but may be behavioral) be charged more for health care?

Your propossal is not progressive/liberal/sensible. It leads to HSA's or other means of self-insurance, since everyone has something that could be ascribed to a behavior that could lead to disease.

BTW, 'Nanny government' is the registered trademark of the conservative political right, so be sure you have permission to use that phrase.

Posted by: JimPortandOR | Jan 25, 2006 5:29:45 PM

Somehow I missed the part where Thompson called for the Government to force employers to do this, rather than him being an individual who encourages Employers to do this.

There is a world of difference between the two things.

The biggest, from my point of view is that Employers would try different means to achieve the goal of encouraging employees to be healthier. Some would work, some wouldn't. Government mandates tend to be one size fits all, and difficult to change once they become entrenched. Also, it is much easier to choose not to work for an employer who goes overboard in a draconian fashion than it is to choose not to work at all if a Government goes overboard in forcing all employers to be draconian.

I think it acceptable to have a 'vice tax' if you can show that the vice actually has costs to society as a whole rather than to merely the individuals who engage in that vice. Collecting funds to defray such a cost seems legitimate. If all the money from smoking taxes went to treat sick smokers, well and good. If though, this is merely a way to get revenue from an unpopular activity and transfer it into general funds it seems fundamentally unfair to me. I think a simple examination of smoking taxes, and where the money goes will reveal which scenario currently predominates.

Posted by: Dave Justus | Jan 25, 2006 5:30:19 PM

don't smokers already pay higher premiums on many types of insurance?

Posted by: mark | Jan 25, 2006 5:46:56 PM

Although it is possible that smokers die younger and thus save the government more money in unpaid social security than they cost in extra health care, I think money is the wrong measure to be using here. Because money is easy to count and to some degree substitutes for well being (most people would consider their well being increased if they received a million dollars) it may seem like a useful measure, but I think it confuses the issue in this case. When you measure in pain free days and years of life without disability then smoking appears as a huge loss for society and that's what we should be looking at in this case. By necessity a government must keep accurate accounts, but it's primary purpose is the protection of its citizens, not accounting.

Posted by: Ronald Brak | Jan 25, 2006 10:27:49 PM

the first hint of the slippery slope:

Yeah man, charge them more, me less

one can read this and think it sensible.

one can then remember that universal insurance is just that: universal.

start discriminating against specific behaviors, and it's no longer universal: it's discriminatory. and it's hard to make a moral case that the poor are entitled to universal coverage, yet those who indulge in specific behaviors are not. especially when the list of specific behaviors is essentially ever-changing with time.

a sad fact is that shared risk must be equally shared, or not at all. that's the price of universality.

Posted by: the dreaming ape | Jan 25, 2006 10:54:30 PM

Personaly I am all about nationalised health care and just taxing the living daylights out of "vice" of all sorts including junk food. I am a smoker and would be hit hard if the price of my rolling tobacco went up but it would likely force me to quit. It would also provide a great way to pay for the increased cost of health care for smokers, drinkers and people who eat a lot of junk food.

Posted by: DuWayne | Jan 26, 2006 12:50:46 AM

Let's face it, as soon as governments start paying for health care, it becomes a compelling state interest to coerce citizens to be healthier. You can talk about the slippery slope all you want, but your arguments are undermined from the start. Citizens receiving care from the state have a civic duty to minimize unhealthy behavior—and given our skyrocketing health costs, will soon have a legal duty as well.

Instead of focusing on obesity per se, we should focus in on hypertension and body-fat percentage. I recommended once that individuals with greatly excessive readings in either be slapped with a punitive 5% income tax, to cover our expaning medical programs. Something like that will come soon, mark my words. And I'm not happy about it.

Posted by: Mastiff | Jan 26, 2006 4:26:24 AM


Posted by: Mastiff | Jan 26, 2006 4:27:33 AM

...Fred, like Kevin Drum's Al, is really just a liberal creative type engaged in a long-running piece of performance art...

Shorter Ezra: We can discuss all risk groups unless it's a protected and favored group. Instead, let's just sidestep the questiona and ridicule anyone. That'll shut 'm up!

Posted by: Fred Jones | Jan 26, 2006 11:48:28 AM

... it's discriminatory. and it's hard to make a moral case that the poor are entitled to universal coverage, yet those who indulge in specific behaviors are not.

That was *exactly* my point. Maybe Ezra like you as the messenger better....

Posted by: Fred Jones | Jan 26, 2006 11:50:18 AM

Ezra, this is the one major issue I have with nationalized health care. (In general I am for it, but this one issue could be a deal breaker.) As soon as the govt is involved in health care, it now has an incentive to regulate any and all "vices" or "unhealthy behavior" and I'm not sure I want the government to regulate my life that much.

It would give the government a reason to regulate everything from promiscuity to drugs (alchohol, nicotine) to what we eat.

Posted by: Tito | Jan 26, 2006 2:13:04 PM

Tito, you might do well to ask yourself how this has played out in other countries with national health care, most of which are probably less inclined toward what we might call lifestyle libertarianism than the U.S. Your concerns aren't grounded in the reality of health care policy.

Posted by: djw | Jan 26, 2006 3:56:49 PM

Is that really what Al is? I thought he was fo' real.

I don't understand this argument about government regulating your habits. Why would they have any more of an incentive than private insurers would? The fact is, the governments answers to us, and with a ridiculous amount of Americans indulging in one vice or another, I just don't see enough politicians lining up to be on the anti-vice force patrol. Its one thing to talk about incentives, its another thing to force people. It would be like if abortion were to be banned tomorrow, 60% of America would instantly get pissed.

Posted by: Adrock | Jan 26, 2006 4:05:53 PM

I just want to say I am all for giving vegetarians lower insurance rates. This is what we're talking about, isn't it?

Posted by: KathyF | Jan 27, 2006 7:23:23 AM

"I just don't see enough politicians lining up to be on the anti-vice force patrol."

Really? It's not "all vices at once". Just one or two at a time. Alchohol was in the past. Smoking is the current favorite target. "Illegal Drugs" (ones not produces by large pharma companies) have been a target since the 50's. Right wingers can (and have) argue that AIDS and other STDs is a result of promiscutiy (or even homosexuality) in the same way lung cancer is the result of smoking.

The problem is that most American's DON'T support each other's vices.

Posted by: Tito | Jan 27, 2006 10:32:40 AM

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