Thursday, January 6, 2011

When Do Bad Individual Choices Cost Everyone More Money?

This thread is being started for the express purpose of continuing to pursue an interesting area of inquiry that a balky Donklephant is hindering here. I'll use a comment of my own as a point of departure:
What’s your basis for believing that society bears a higher overall financial cost for obesity?

Since it limits lifespan, there’s plenty of reason to believe that a taxpaying and bill-paying society benefits financially from letting people made bad health choices and die sooner. That thins the herd, and preserves sparse resources for things like medicare and social security. Thereby financially benefitting those who make the allegedly wiser health choices.
I wish I had simply said "there's reason to speculate that." An error of enthusiasm, one that I would not expect to get clobbered on if I were talking with folks committed to good-faith inquiry.

This post will almost certainly be revised to add more stuff later. But I look forward to hearing from folks as soon as they have time and feel like it.

UPDATE: I'll try my best to summarize my lines of thought and some of the relevant questions that I wonder about on this issue.

At base, we're talking about what personal failures might legitimately justify paternalistic intervention by, say the government, or maybe an insurance company. That's a very broad and fundamental question. And obviously, even though lots of us don't like the idea, we know that it has been happening for a long time in areas of broad cultural agreement (you go to jail for your habit of violence, you may pay higher insurance rates for a poor driving record, and so on).

What we also know is that such intervention is slowly but surely seeping into areas where there isn't nearly as broad a cultural agreement on right and wrong and fairness of penalty.

Miscellaneous random questions and concerns, numbered for ease of reference:

1. How far down that road do we want to keep going?

2. When do me mistake petty resentment for moral rectitude?

3. Are we counting everything? If not, what is the basis for counting within a more limited domain?

4. Do all people who make bad health choices incur higher medical costs that are subsidized by folks who make "good" choice? Or Only some. If only some, which ones?

5. What is the difference in average "end of life" costs for a "good chooser" versus a "bad chooser?"

6. How much more, annually, does it cost taxpayers in social security costs for every additional year of lifespan?

7. In general, do good health efforts undertaken by employers and health insurers increase or decrease total healthcare costs? Which ones?

8. Which cost figures should we use when we try to perform such calculus? For example, if the list price of an MRI is, I dunno, $900 but insurers only pay $590, how should we do the math?

8. Should good health efforts be pursued further only on the basis of cost savings, or should they be pursued simply as a matter of moral rectitude?

That's probably more than enough. I should be upfront, that my basic bias here is a visceral reluctance to go much further down a road where more and more of our private human behavior is scrutinized, judged, and affixed with a dollar figure of penalty or reward. It seems like a fools errand, like it will lead to a more unpleasant, more exhausting world where our real choices are ever more constrained. I see a sort of a statist business-government beast that won't actually deliver healthier happier more prosperous people, but will still crawl up our arses at every opportunity.


  1. Just to be annoying, while the correlation link is certainly there the causation link is still somewhat dubious at lower levels of obesity. By which I mean that at the "lower levels" of obsity being overweight may be more of an indicator of bad habits (or lack of good habits) than itself a causative factor for morbidity. If you don't get enough exercise, well, OF COURSE you have a higher risk of high BP, stroke, and cardio disease. And of weighing more.

  2. Another ball to juggle in one respect. But your point doesn't really disturb the contentions of some that we need to make sure folks behave properly, for their own good.

    In other words, obesity isn't the per se cause of increased morbidity, but the bad choices still are.

    And I don't think that anyone seriously wants to argue against the idea that bad choices leads to undesirable consequences, right? Moreso, we're wondering what our responses should be to that obvious bit.

    Still, it's a point well taken that if we the people choose to act to curb the bad choices, we need to better identify exactly what the most proximate adverse choices are.

  3. I had to go through the password-recovery process to comment, and I'm using my wife's laptop, which is annoying to type on. So I'm just going to say hi for now.

  4. But your point doesn't really disturb the contentions of some that we need to make sure folks behave properly, for their own good.

    Of course not. Nothing will derail those who want to control the lives of others but a swift boot to the balls, frequently repeated, with a hearty "Eff off, Nazi." Have we learned nothing from the Religious Right? Do we think the Loonie Left would be any better?

    The crux of the issue is freedom, which some people are firmly against, at least for others. And that's one of biggest problems with socialistic schemes. As soon as "the state" is picking up the tab, such people (and the state) feel morally empowered to dictate to others how they must behave, under the excuse that said behavior affects everyone. Your rights vanish in direct proportion to the amount of personal responsibility you abdicate, but you're not allowed the option to maintain your personal responsibility.

    The Founders well understood this principle, and tried very hard to set up a system that let people go to hell in their own way while protecting others. We can understand things like car insurance -- your actions in driving can indeed directly affect others. But obesity? The main effect is on you ... until everyone else is picking up the tab.

    And, of course, once the state's already obtained the punishing coercive power it wants and is picking up the tab for the failures, it does not have the same motivation to address the results of personal actions as an individual might have. You are dependent on the state to "fix" your problems for you, but the state's power grab is aimed at "prevention," not cures.

    Here's a cautionary tale about nanny-statism in regard to obesity. It took Mr. Mason fifteen years to get the gastric bypass he really needed. Behavior mod and tsk-tsking weren't going to help.

    I picked a British example as lefties seem to love the NHS so much, but the nanny-statism is creeping into all corners of British life. Once you hand over that personal responsibility, limits on what the state can do to curtail your freedoms tend to diminish rapidly in ALL areas of life.

  5. Truly lovely introduction to that rant. And much of it rings true to me.

    Not sure how many folks agree with the idea that a given obese person needs a gastric bypass. I'm certain some fraction of obese persons have disorders and conditions that mean that a gastric bypass is the most appropriate treatment. This guys sure seems like one of them. I suspect that's not the common view, though.

    And it's sort a peculiarity to call denial of the bypass coupled with demands to take personal responsibility nanny-statism. It's more of a kernel of personal responsibility embedded in a nanny state beast. An odd case.

    Another peculiarity of the debate over health insurance and the nanny state is this: if we were to go largely private provision of insurance, it's quite likely that health insurance companies would undertake many of the same nannyish approaches as any NHS: they'd have an extremely high threshold for providing gastric bypass, they'd try to adopt invasive punitive measures for unhealthy behavior, and so on.

    So if you wanted to smoke or overeat, you'd pay for it. Your freedom would be constrained to paying for the privilege or shouldering all the costs on your own.

    Of course, any libertarian would in theory rejoice at that "shouldering the cost on your own" bit. But in practice, they'd likely get stuck cost shopping in a very suboptimal free market. Smokers would probably have to form a co-operative not to get poned by health insurance companies determined to pone them. Spartan health nuts would form their own co-ops, too. We'd end up with all sorts of weirdo clubs.

  6. Why, thank you! I do sincerely detest people telling other people what to do for moralistic reasons. It's true that if your actions materially impact others there's at least some rational basis, but the manufacturing of that basis by mandating that impact ... let's just call it disingenuous, which sounds so much better than "outrageous control-freak bullshit."

    it's sort a peculiarity to call denial of the bypass coupled with demands to take personal responsibility nanny-statism.

    Somewhat, perhaps, but read the article again. It illustrates the complete absurdity of that demand in Mason's case when his ONLY source of care was government and the problem was obviously outside of his control. When he was told "ride your bike more" he was already well over 400 lbs. When he begged for a referral to an eating-disorder specialist he was over 900 lbs ... and they sent him to a dietitian instead. It took him fifteen years and three suicide attempts to get the treatment he needed, which in the US he'd have gotten within a year or so even under MCD in most states. But the NHS was created under the best of intentions, of course.

    FYI: Bariatric surgery is the #1 recommended clinical treatment for morbid obesity, and at 400+ lbs Mason was already well over that diagnostic threshold. UK cost, £8000.

    As for what would happen under a strictly private insurance world, let me know when we have one and we'll find out. That hasn't been one here for several decades -- the vast majority of the US populace depends on either employer or government, not on themselves. Oddly enough, a few places like Switzerland have largely private setups and seem to do fairly well with them. Of course, they also have an individual mandate, required acceptance, and set minimum standards for the basic required policy. But they keep it pretty basic. Past that basic coverage, you're completely on your own.

  7. Yeah, I didn't mean much by the comment about the odd kernel, it just seemed worth remarking upon.

    Bypass is sure expensive. And so many folks look at at individual choice and don't want to support such expensive intervention.

    But here's the thing even the least charitable among us should consider. Once we've GOT a 600 lb man, and he can't really do anything anymore, due to his bulk, our culture will we insist on supporting him. At that point, spending 30 grand to turn someone into a reasonably healthy and possibly productive adult is a bargain.

    That mandate/basic minimum standard for coverage is IMO really essential for coming to grips with healthcare. I wish we could all sort of get over that.

    Offtopic fyi: I actually heard a Republican, John Thune, say that we may need to consider means-testing to save social security. I know very little of Thune, but this seemed like a peculiar idea for a Republican to mention. Any thoughts?

  8. It's not exactly a unique idea in the GOP, and I don't understand why it should seem so unique an idea for the GOP. Nor is means-testing MCR -- in fact, MCR is already means-tested as to the level of premiums paid. That was a part of the 2003 act, which was, I point out, written and introduced by GOP Congressional leaders and pushed into law by them and W.

    Yeah, a standard basic policy is practically required for any sane reforms.

  9. I don't know why you find that so odd (means-testing coming from Republicans). It was the GOP that pushed in means-testing for Medicare premiums not all THAT long ago. (Medicare Act of 2003, authored by Denny Hastert at the urging of W, passed by a GOP-heavy but bipartisan majority in both houses, and signed into law by W.)

    Conservative thinking on entitlement programs strongly leans towards the "safety net" view. Until, of course, it's their personal turn to collect those checks ...

    If you start with the presumption that reforms are needed (and they are) and that all options should be on the table, then certainly means-testing must be one of the options. I personally find means-testing far preferable to raising the retirement age, or cutting benefits at the lower ends of the ladder.

  10. It's unusual as a matter of my accumulated personal experience as to who says what about reforming social security

    In other words, Thune is the first republican politician that I have heard say that mean-testing might need to be part of the solution. By comparison, you can always find a liberal to surmise that the solution is to pone the wealthiest.

    As we both know, there's a difference between acknowledging that "pone the richest" is the least unpleasant viable solution, and offering it as your default solution. And the latter is the form that's going to generate "pone the rich" most often, right?

    BTW, I don't mean anything rhetorically by "pone the richest." Just being glib for the sake of expedience. An allowed indulgence at one's own blog, I hope.

  11. Kind of an aside, but I wonder how many reflexive "pone the rich" libs even realize that the US tax structure is already far and away the most "progressive" among advanced nations.

    Or how it got that way -- other nations with massive entitlement structures started out "progressive," then radically expanded the cost of such programs paid by the lower income strata as they discovered that there really weren't enough of the rich to feed everyone. And that the rich they had were, in my words, not only gristly and hard to chew, but also peripetatic and hard to catch.