The Tension Between Public Healthcare and Personal Health Habits

November 23rd, 2009 by Jacob Rheuban
1 Comment Law and Society, Life

Does societal responsibility for individual health needs give rise to individual responsibility to maintain health?

The proposed changes in healthcare have consumed a fair portion of media attention over the past few months.  Much of the debate revolves around the provisioning of healthcare to American’s.  But buried deep in the discussions is some talk about preventive care and the role that health maintenance plays in America’s overall healthcare policy.  President Obama’s healthcare policy discussion mentions individual responsibility for preventative care:

“Barack Obama and Joe Biden believe that protecting and promoting health and wellness in this nation is a shared responsibility among individuals and families, school systems, employers, the medical and public health workforce, and federal and state and local governments. All parties must do their part, as well as collaborate with one another, to create the conditions and opportunities that will allow and encourage Americans to adopt healthy lifestyles.”[1]

The proposed changes in healthcare represent, to some degree, a movement towards increased public responsibility for the health of individuals.[2] If society shoulders some of the burden of individual healthcare issues, then an individual’s health habits have, in addition to personal health consequences, external repercussions.  This begs the question:  If society takes responsibility for the health of its citizens, do the citizens have a corresponding responsibility to society to maintain their own health?

Why subsidize healthcare?

It seems that there are two primary factors that give rise to a need for government subsidized medical care:

  1. An individual’s medical issue that requires care
  2. Inability or difficulty of the individual to cover the financial cost of the required care.

To the extent (1) an individual’s health habits create, or fail to control, medical issues, and (2) the burden of those medical issues falls on societal resources, that individual’s health habits can have an impact on society at large.  The individual may suffer the personal pain and suffering associated with the medical condition, but the financial and medical resource burden may be largely external.[3]

If a beneficiary of a healthcare subsidy can reduce his need for  medical care by reducing his medical issues, should he be required to do so?  Should the receipt of healthcare benefits be conditioned on the certain minimal efforts on the part of the beneficiary to maintain his health and control his healthcare needs?

Should individuals be required make certain efforts to maintain good health?

Take for example an individual who has lung problems from smoking.  Despite repeated warnings from doctors that he terminate the unhealthy habit, he continues at the rate of over a pack each day.  Every year he visits the doctors with his condition worsening, requiring more medical care and more public resources to provide that care.  To the extent that this individual can reduce his healthcare needs by reducing his cigarette consumption, does he have a responsibility to do so?  Stated differently, to the extent that society lends a helping hand to those in need of medical assistance, is there a corresponding responsibility that individuals in receipt of such assistance do what they can to improve their own health?  If so, should healthcare benefits be conditioned upon such efforts by the individual?

Can health habits be effectively regulated?

The conditioning of healthcare benefits on certain individual health maintenance requirements would require some standards for healthcare maintenance.  This is an obviously complicated issue with no answer that seems both simple and comprehensive.  Should individuals who smoke be denied healthcare benefits?  If so, how much do they have to smoke in order to be denied such benefits and how is that quantity of smoking effectively tracked?

In addition to the practical problems with tracking and regulating the health habits of individuals, attempts to condition healthcare benefits on health habits raise other issues.

Is it inhumane or uncivilized to withhold healthcare from people who make unhealthy living choices?  To many, the withholding of medical assistance may seem to reflect particularly coarse policy.  The United Nations Declaration of Humans rights lists medical care as one of those rights[4], and many Americans may share their view.  If America adopts a healthcare system that provides greater coverage for all citizens, it may be reasonable to interpret this as evidence of a belief that access to healthcare is a human right.

Further, the regulation and monitoring of health habits such as smoking and diet may conjure images of an Orwellian state.   Many American’s may be understandably uncomfortable with government supervision of their dietary and tobacco habits.

Taxation:  the simple health incentive?

Perhaps a simple solution to this is to tax unhealthy behavior.   For example, the healthcare burden of cigarettes could be passed on to smokers in the form of a per pack tax on cigarettes that gets paid into a lung cancer treatment fund.  In a way, smokers would be prepaying for treatment of smoking related issues.[5] Additionally, the tax would serve to deter partaking in the unhealthy habit.

In an earlier post I examined proposed junk food taxes and discussed  issues related to policies that tax unhealthy habits.  This type of tax raises a variety of issues.  For example, what should be taxed?  If cigarettes are taxed, what about junk food?  Should potentially dangerous activities like sky diving, sexual promiscuity or excessive unprotected sun exposure be taxed?  Taxing days at the beach without sunscreen seems absurd.  Further, moderate consumption of unhealthy items like junk food and cigarettes is unlikely to have a significant enough impact on health, and corollary public burden, to give rise to a significant public interest in the activity.  But without taking taxation to that absurd level, is there some level of taxation that would provide an appropriate and palatable incentive for people, to a certain degree, to lead healthier lifestyles?  Could such a tax also be used to subsidize the costs of treatment for conditions resulting from the unhealthy activity?

What about the well insured?

Much of this discussion is based on the premise that individual health choices have external repercussions (externalities in economist speak).  However, some individuals with resources may shoulder a substantial burden of their healthcare needs.  If an individual is well insured, or has the resources and intent to pay for the full impact of his medical needs, then his health habits may have little external impact on society.  If an individual’s health habits have little impact on society, does society have any fair interest in regulating or incentivizing his health habits?

Do healthy living habits really lower medical costs?

There is some debate over the true lifetime costs of treating smokers’ health issues.  Some studies suggest the longer lifespans of individuals with healthy habits give rise to additionally health costs.[6] That is, healthy people live longer and thus consume healthcare resources for additional years of life.  Further, as healthy individuals age, they may encounter expensive to treat medical issues.   Conversely, smokers and other individuals with unhealthy lifestyles have shorter life expectancies and thus cost less to support.  Or that at least the cost of treating smokers is to some extent mitigated by their short life.  This seems to suggest that there is an external cost of living a healthy lifestyle, exhibited in the form of healthcare costs during the additional years of life.  The existence of these studies raises a question over how to properly calculate an individual’s healthcare burden on society.  Should the cost be calculated on a per-lifetime basis?  Or should it be calculated on a per-year of life basis?

The future of preventative healthcare policy

Formal public policies geared towards the regulation or taxation of health habits will undoubtedly be controversial.  Some may even suggest that the conundrum created by societal provisioning of healthcare for individuals, and resultant interest in society in individual health habits, provide an argument against public provided healthcare altogether.  But if health for all is indeed a societal goal, then in addition to macro-societal efforts, individuals will need to commit to doing their part to care for their own health.  As President Obama says:

“Preventive care only works if Americans take personal responsibility for their health and make the right decisions in their own lives – if they eat the right foods, stay active, and stop smoking.”[7]


[1] http://www.barackobama.com/pdf/issues/HealthCareFullPlan.pdf


[2] There seems to be a good deal of debate over whether the proposed reforms to healthcare are tantamount to socialized healthcare. Regardless of whether or not we are on the cusp of a truly socialized healthcare system, the plan does seem to represent a movement towards greater societal responsibility for individual health needs.

[3] Many medical issues pose two burdens on an individual:  (1) the pain and suffering from the medical issue and (2) the financial burden.  These two burdens serve to incentivize individuals to make efforts to avoid medical issues.  If public provisioning of healthcare removes the financial burden, then some of the incentive to remain healthy could potentially also be removed.  This effect would be largest for conditions for which pain and suffering is minimal but financial burdens are high.

Additionally, for some conditions there may be a trade-off between pain and suffering and financial burden.  For many non-life-threatening medical issues, individuals may choose to endure a certain degree of discomfort to avoid the financial costs of treatment.  If there is no cost of treatment, individuals may be incentivized to seek medical treatment for otherwise tolerable issues.  Again, this effect would be largest for conditions for which pain and suffering is minimal but financial burdens are high.

[4] http://www.un.org/en/documents/udhr/

[5] How much should this tax be?  A 2004 report by the Center for Disease Control estimated the annual healthcare burden of approximately $96 billion.[5]  The estimated healthcare burden of cigarettes range from $7 per pack[5] to $41 per pack[5].  To the extent that these healthcare costs are borne by society, as opposed to the individual smoker, they represent an externality.  Meanwhile, current cigarette tax rates in the US range from $0.07 to $3.46[5].

[6] http://www.law.umaryland.edu/marshall/crsreports/crsdocuments/97-1053_E.pdf

[7] http://www.barackobama.com/pdf/issues/HealthCareFullPlan.pdf

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One Response to “The Tension Between Public Healthcare and Personal Health Habits”

  1. Deb Rheuban says:

    Great post. When I try to understand healthcare reform I tend to focus on the industry rather than the individual. I think that individual habits have a lesser effect on healthcare costs than the people and companies that profit from medical care. For example sometimes in preparation for surgery an individually wrapped sterile pen is used to mark the surgical site…it is used once and than discared. I would love to have that contract. Good medical care should not be so expensive.

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