The biggest problem our national health care system faces is the mismatched soldering of a private insurance delivery onto a public-right-to-health mentality. Conservatives want to return to a pure version of the former in order to bring efficiency and line up incentives properly. They want individuals to be able to pool risk, but ultimately be responsible for health choices and desired health care. Liberals, myself included, look to the latter and think we should start looking at health care like education - something that we collectively pay for and collectively provide.
For that reason, I couldn’t disgaree more with Charley when he writes,
We are getting serious about prevention in the new law: Insurers will be able to charge smokers higher rates, and will be allowed to reward healthy, preventative behaviors. Only makes sense.
No, it doesn’t make sense. Do smokers - over their lifespan - really utilize health dollars more than nonsmokers? After all, premature death from a relatively acute disease means that the state is spared the immense cost of sustaining life through long chronic illnesses that come with old age. That’s no reason to be sanguine about smoking-related illness or stingy with treating chronic illness of course - there’s the immense personal toll on people’s lives - but the argument that “tobacco is costing us money” is a smokescreen.
In general, our health system does a good job at treating - or discovering how to treat - acute diseases. What it doesn’t do well is alter people’s lifestyle dispositions that lead to chronic as well as acute disease. I remained unconvinced, but open-minded, that increased spending in this area is going to be very effective. But at the very least the state singling out one lifestyle disposition for coercive persuasion isn’t a model that’s going to do any good when you start talking about heart disease, diabetes and the like.
Beyond that, I’m uncomfortable with the state applying actuarial logic to provision of health care. Do we charge more for people who drink soft drinks because of diabetes risk? What about people who drive instead of walk? If gay men have a statistically much higher chance of contracting HIV does Massachusetts charge them more for health care? People who lay out in the sun get skin cancer; why not a beach surcharge? Yes, I’m being a little flip, but all of these are lifestyle-factor questions that are serious. How do you cut the actuarial pie? If you put great stock in the moral hazard argument, why bother with public health care to begin with? Why not take a conservative insurance-voucher approach?
I’m not a smoker - yes, because smoking is really terrible for one’s health - but as always in these matters, I suspect there’s a New Prohibition mentality that relishes the encroachment of the state into people’s behavior. I even sense that some people with strong pro-legalization attitudes toward recreational drugs would have no qualms about making tobacco a controlled substance.
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