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 Specifications

A number of criteria have been proposed by Dubois and other analysts, which offer reasonable grounds for striking an ethically appropriate balance between completely ignoring unhealthy behaviors and appreciating the many barriers that make it difficult for individuals to live a healthy lifestyle. Four proposed standards help to inform the discussion.

Feiring (2008) and Pearson and Lieber (2009) propose that differentiated plans should be imposed only prospectively for voluntarily refusing to take any action to change one's unhealthy behaviors. With this standard, people would not be charged more for coming into a plan being overweight or smoking but for stating that they are not willing to try to do anything about them. Applying this standard would recognize that health status is patterned by social position while acknowledging that it is not "determined," that is, that the majority of poor people do not smoke, are not obese, do not drink excessively, and have some physical activity in their lives (arguably, with some quibbling at the margins), and therefore, that it is reasonable to ask others in the same position to do the same. This standard entails two stipulations: first, that the proposed voluntary action that would demonstrate the good faith effort to be a contributing member to the collective goal of using limited resources prudently is accessible, and second, that it is the effort, not the outcome, that counts. It is sufficient that the member enroll in a smoking cessation program or weight loss program and not necessary that they achieve abstinence or a BMI of 25 to avoid being penalized.

Second, members should be offered a range of options to fulfill their obligation to contribute to the good of the collective enterprise. Unfortunately, there is a high correlation among the most common behaviors that are used to define an unhealthy lifestyle: smoking, drinking, overweight, and sedentary. Rather than asking people to take action to address each of these problems independently, allowing people to choose the issue that they would like to address first demonstrates sympathy and solidarity with their efforts to overcome hardships. The measure also promotes the exercise of autonomy, which has also been linked with better health.

The third standard is setting limits on the range of behaviors that should be considered for inclusion as unhealthy. Members should not be required to change behaviors such as sexual behaviors, childbearing, sexual orientation, and participation in sporting activities that elevate risk of injury because the harm of proscribing them would far outweigh the benefits to be gained by their reduction or elimination.

Each of these standards needs further specification, so the final recommendation is to leave these details to be resolved through a procedural process, such as Daniels and Sabin's (1997) accountability for reasonableness. Insurance companies should be required to present a public rationale for meeting these standards, an accounting of the anticipated benefits, and an appeals process for exempting individual cases, with a public review and rating process.