Editor's Choice

Health insurance and personal responsibility

Conor Friedersdorf -- currently blogging for the Atlantic's ideas blog -- made an interesting point about this WSJ op-ed about grocery chain Safeway's health-care plan. In the op-ed, Safeway's CEO touted how his company's health-careplan emphasized personal responsibility as a means to control costs:

Safeway's plan capitalizes on two key insights gained in 2005. The first is that 70% of all health-care costs are the direct result of behavior. The second insight, which is well understood by the providers of health care, is that 74% of all costs are confined to four chronic conditions (cardiovascular disease, cancer, diabetes and obesity). Furthermore, 80% of cardiovascular disease and diabetes is preventable, 60% of cancers are preventable, and more than 90% of obesity is preventable.

As much as we would like to take credit for being a health-care innovator, Safeway has done nothing more than borrow from the well-tested automobile insurance model. For decades, driving behavior has been correlated with accident risk and has therefore translated into premium differences among drivers. Stated somewhat differently, the auto-insurance industry has long recognized the role of personal responsibility. As a result, bad behaviors (like speeding, tickets for failure to follow the rules of the road, and frequency of accidents) are considered when establishing insurance premiums. Bad driver premiums are not subsidized by the good driver premiums.

This seems like an expression of a classic conservative position: In the last analysis, individuals can shape their living conditions in a meaningful way and consequently can be held responsible for their own suffering. Charging high-risk people ("fair risk pricing") more for their insurance seems to make good common sense; they should have their insurance coverage supply a sort of moral hazard. Probably no one says to themselves, "Fuck quitting smoking. If I get lung cancer, my insurance will pay for it," but they may not take the sort of precautions to prevent illness because nothing in the structure of their lives provides a incentive counterbalance to the immediate pleasures (such as they are) of smoking, drinking, eating poorly, getting a tattoo, etc. (It's worth noting that currently, in some private plans, certain sorts of preventive care are regarded as elective care and thus are not always covered.) It seems obvious to build an insurance system that rewards healthy behavior in patients and penalizes known unhealthy behaviors.

Friedersdorf says as much, but also points out the downfall of such a plan -- where do you draw the line on what sort of behaviors insurance companies should be permitted to police? Isn't monitoring for "unhealthy" behavior a wedge for introducing Minority Report-style total surveillance? With a note of libertarian alarm, Friedersdorf writes, "Smoking today. Alcohol, downhill skiing, and premarital sex tomorrow? Pricing unhealthy habits means testing for them in ways intrusive enough to reliably detect them. What are your vices? Do you want your employer or your government determining which vices cost you money?" Or do you even want that data, for that matter, cataloged somewhere, becoming an albatross around you worse than a credit report? Instead of prison-inspired panopticism, perhaps the Foucaldian nightmare that awaits us is a medicalized one, along the lines of The Birth of the Clinic. The state derives new power and leverage from its control of the social definition of health.

Of all the arguments against nationalized health-care, this seems to me the strongest: that once taxpayers are footing the bill for the avoidable health risks other citizens take on, it's only a matter of time those taxpayers demand further regulation of those risk-taking individuals' behavior. And whether or not something constitutes a health risk is open to a lot of interpretation (think of the nebulous studies that lead science writers to proclaim the health risks or benefits of caffeine, red wine, etc., etc.) -- it could become a site of ideological struggle, with healthfulness being used as a pretense to prescribe certain standard, predictable ways of life. After all, insurers' main concern is risk that can't be anticipated and controlled. The social pressure toward conformity could become even stronger than it already is now. It's a wonder old-school conservatives -- who want nothing more than to prescribe a "traditional" lifestyle -- aren't more in favor of state-supplied health care.

Perhaps the future of health care will involve private insurers undercutting the cost of the state-offered plan, and a mandate that all individuals be covered. (That's part of what makes the auto-insurance market work.) If you want to pay extra for privacy, you can opt for the national plan. If you are comfortable having your health data monitored to save a few dollars, a private insurer could offer that.

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