Should People With Unhealthy Lifestyles Pay Higher Health Insurance Premiums?

David R. Buchanan


J Prim Prev. 2011;32(1):17-21. 

In This Article

Ethical Considerations in Designing a Differentiated Plan

The fact that covering the higher medical expenses of people with unhealthy lifestyles on an annual basis means that others in the same plan will have to forego other possible plan benefits (e.g., eye care, dental care; or higher pay raises) is the nagging rub that points to the larger issue of honoring a social contract based on mutual obligation and mutual responsibility. There is a general sense that, if everyone did not smoke, maintained a healthy weight, drank only in moderation, and got some regular exercise, plans would cost less and/or be able to pay for procedures that they cannot now afford. Is there an ethically acceptable means to achieve the goal of assuring that all members of a collective cooperative scheme are making a comparable, honest effort at doing that which is within their power to use limited resources prudently? What sorts of ethical considerations weigh against using financial incentives to remind people to be mindful of their obligations to one another?

Dubois identifies several important ethical concerns. The most significant is that charging people more will fall disproportionately on those who already have less. Without careful crafting, charging higher premiums may further stigmatize those who are more likely to feel bad about themselves already, and it may act as a further disincentive to obtaining medical insurance, thus, exacerbating existing health disparities. As Dubois notes, its implementation may also harm third parties such as dependent children; due to the inherent opportunity costs, paying for a child's braces, for example, may no longer be affordable in families of less financial means. Finally, Dubois points out that monitoring and enforcing compliance in such schemes will inevitably prove costly. (Again, by analogy, both divorce settlements and car accidents reports have moved towards no-fault claims, due to the high costs involved in seeking to assign or apportion blame.) He raises a couple of other issues that seem less compelling. Is it a form of state coercion? It depends. Whereas it is easy to imagine horribly intrusive requirements, it is equally possible to identify terms that may not be particularly bothersome. Is it a violation of an existing social contract or an infringement on a right to health care? There are a range of existing remedies that lessen the magnitude of these concerns (such as switching insurance plans or voting in the opposing political party).

For my purposes, an interesting point raised by Dubois is the ambiguous effect of such plans on the issue of social solidarity. Schmidt (2008) describes how German law pertaining to health insurance avers an inextricable link between personal responsibility and social solidarity. The relevant section of the act, titled "Solidarity and Personal Responsibility," reads,

In the spirit of a mutually supportive community [Solidargemeinschaft], the task of the statutory health insurance is to maintain, restore or improve health of the insured. The insured have co-responsibility for their health; through a health conscious way of living, taking part in appropriately timed preventative measures [and] playing an active role in treatment and rehabilitation, they should contribute to avoiding illness and disability and overcoming the respective consequences. (p. 200)

Here, the act of actively taking care of one's health is seen to be an expression of one's participation in contributing to a collective common good. Such schemes incentivize and reward those who behave in ways that benefit the collectivity as a whole. Conversely, however, these same plans can be seen to undermine social solidarity because such meritocratic elements may be viewed as primarily benefiting those who are already advantaged and by eroding traditional notions of giving without expectation of return. In short, the issue is whether plans can be devised that benefit the least well off and reinforce the sense of social solidarity.