With health insurance access being widened under Obamacare, attention is focused on groups that, presumably, place disproportionate burden on the health care system — mainly smokers and the obese.
But the new health care law treats these two groups very differently, and the facts as to who imposes more cost on the system are disputed.
Whichever way the science tilts, it is clear that as health care becomes a collective concern, the next step to collective interest is unhealthy individual behaviors.
"Your freedom is likely to be someone else's harm," Daniel Callahan, senior research scholar at a bioethics think-tank, the Hastings Center, told the Associated Press.
This public interest in private behavior is written into the Affordable Care Act, which allows insurers to charge up to 50 percent more for longtime smokers, even though it prevents all other forms of health-based price discrimination.
Obesity, for example, cannot be penalized under the new law, something Callahan hopes to change. He issued a recent paper calling for "fat shaming," mobilizing public pressure to stigmatize overeating.
"As a smoker, I was at first criticized for my nasty habit and eventually, along with all the others, sent outside to smoke, and my cigarette taxes were constantly raised," Callahan wrote in the article. "The force of being shamed and beat upon socially was as persuasive for me to stop smoking as the threats to my health. … Why is obesity said to be different from smoking?"
"Only a carefully calibrated effort of public social pressure is likely to awaken them to the reality of their condition," Callahan wrote, "They have been lulled into oblivious-ness about their problem because they look no different from many others around them."
But critics note a disconnect on the costs of smoking, and, by implication, obesity. The open secret is that smokers, on average, cost the health care system much less than do healthy people, simply because they don't live as long.
Vanderbilt University's Kip Viscusi found that for every pack of cigarettes smoked, the country saves 32 cents on health care. "It looks unpleasant or ghoulish to look at the cost savings as well as the cost increases and it's not a good thing that smoking kills people," Viscusi told USA Today in 2009. "But if you're going to follow this health-cost train all the way, you have to take into account all the effects, not just the ones you like in terms of getting your bill passed."
Likewise, a 2008 Dutch study found that lifetime health care costs for smokers were about $326,000 from age 20 on, compared to about $417,000 for thin and healthy people, as the New York Times reported at the time. Obese people fell in between, costing $371,000.
The reason, the study found, is that healthy people live longer, but those latter years still heavily burden the system. The total cost burden of healthy years plus costly end-of-life years is thus much higher for longer-lived people.
Healthy people lived 84 years, the Dutch study found. Smokers lived about 77 years and obese people lived about 80 years.
"Smokers and obese people tended to have more heart disease than the healthy people," the Times reported. "Cancer incidence, except for lung cancer, was the same in all three groups. Obese people had the most diabetes, and healthy people had the most strokes."
Eric Schulzke writes on national politics for the Deseret News. He can be contacted at eschulzke@desnews.com.