Should People With Unhealthy Lifestyles Pay Higher Health Insurance Premiums?

David R. Buchanan


J Prim Prev. 2011;32(1):17-21. 

In This Article

Abstract and Introduction


This commentary sets the article by Dubois on the ethical justification for charging higher insurance premiums for people with unhealthy lifestyles in the context of US health care reform. It reviews the relevance and strength of normative concerns identified by Dubois about the acceptability of such differentiated "means-tested" plans. It identifies key issues involving whether certain health behaviors matter ethically, and if so, the grounds that would justify an obligation for people to take action. The article frames the answer in terms of the need to achieve an ethically acceptable balance between the principle of equality and principle of merit and concludes with four ethical standards to focus the terms of the debate.


The article by Dubois that appears in this issue does an admirable job of pointing out the many ethical concerns raised by the increasingly common practice of charging different rates for health insurance premiums based on one's health behaviors (e.g., smoking) or health status indicators (e.g., BMI, blood pressure). In this commentary, I would like to set these issues in the context of health care reform in the United States in order to highlight key issues that might inform the terms of the debate about its ethical acceptability here. The central concern raised by Dubois is whether or how charging people with unhealthy lifestyles more for health insurance than people with healthy lifestyles can be ethically justified.

In the US (and other industrialized nations), there is tremendous concern about containing escalating health care costs, which consistently outpace inflation. A number of mechanisms have been implemented to try to control these perpetually rising expenditures. One means is the use of capitated health care plans such as health maintenance organizations. (In capitated plans, enrollees pay a set amount for a given year of coverage, where the provider must absorb any additional costs if the services provided exceed that amount.) Another is the growing practice of charging copayments for health care visits. Reliance on a competitive market system is praised by proponents for promoting efficiency, and therefore, cost-savings (with contentious empirical evidence; see, for example, Woolhandler et al. 2003; Aaron 2003). Denying coverage to people with existing disease conditions (e.g., cancer, AIDS) is another way for individual companies to contain costs. The article by Dubois addresses the normative issues involved in financially rewarding or penalizing members of an insurance pool for engaging or failing to engage in preventative behaviors. Underscoring the controversy, Pearson and Lieber (2009) note that the initial federal Health Insurance Portability and Accountability Act (HIPAA) mandated that all workers covered under an employer-sponsored health plan pay the same premiums regardless of health status. However, federal authorities finalized rules in July 2008 granting exceptions from HIPAA for certain wellness programs, where employers can now offer rewards or penalties of as much as 20% of the total cost of covering an employee. Is this ethically warranted?

As Dubois explains, charging more for unhealthy behaviors is a form of cost-shifting. Where capitated health care plans shift the burden of controlling costs onto the health care provider, health insurance plans prorated on the basis of health lifestyle shift a share of the costs from the insurance company to the consumer. Copayments for medical visits are another means of cost-shifting to the consumer, but they also illuminate important differences with the differentiated plans under discussion here. First, copayments are applied universally and unconditionally, in contrast to the sort of "means-tested" system of charging different rates depending on one's health behaviors or health status. Second, copayments are intended to discourage unnecessary use of medical services, where differentiated plans are intended to encourage the adoption of healthy behaviors. Requiring people to do something actively is generally considered more intrusive and more onerous than asking people to refrain from doing something. These two issues—whether everyone should be treated alike, or whether there are ethically salient characteristics that justify differential treatment, and whether there are ethical grounds for obligating people to take certain actions—lie at the core of the controversies surrounding this policy.

One option is no-fault health insurance. This has been the prevailing system until relatively recently, and it is consistent with the established medical ethos of refraining from passing judgment and treating patients irrespective of the cause of their condition. The alternative is to maintain that these behaviors matter ethically, and therefore, rates should be calibrated based on the principle of merit, charging people according to what they deserve or have earned. The ready analogy here is offering discounts to drivers with safe driving records. To anticipate, if one accepts that both positions have some validity, then the challenge becomes specifying the conditions that can achieve an ethically appropriate balance between these conflicting moral principles.