Does Mandated Insurance Mean More Paternalistic Public Health Policy? Hopefully Not.

There are several questions I’ve been toiling over lately related to health care spending, public health, and paternalism. Here are three:

  • If the state requires everyone to have health care, does that mean the state should necessarily have a larger role in improving public health?
  • If my tax dollars or insurance contributions go to pay for a smoker’s lung transplant, is that unfair, and does it give me a right to snatch cigarettes from strangers’ mouths?
  • And at the extreme end, does federally mandated health insurance also justify more paternalistic policies to improve our individual health?

My hunch is that the answer is “no” to all three, although they do raise difficult issues. These aren’t abstract questions, either. In fact, they’re questions that are often raised in Britain, where the National Health Service is funded from general taxation and whose public health policies are often more paternalistic than those in the United States. They are also the questions that are likely to get asked in the U.S. now that President Obama has signed legislation that requires every American to have insurance.

In Britain, because the NHS is funded by taxation, everyone in the country is required to pay for the cost of medical care. However, the amount each person in Britain pays into the NHS is not proportional to what they take out in the form of services, medications, and care. In effect, the healthy, tax paying public are subsidizing their unhealthy peers who require health care. This subsidy involves a form of wealth transfer from the healthy to the sick, from the young to the old, and from those who to have been fortunate to avoid accidents to those who have not been so fortunate. It also means that individuals who do not take care of themselves spend money that I have contributed into the health care system, leaving less money in their for me.

Some of the wealth transfers may clearly appeal to large swatches of the electorate and are easily justifiable (e.g, the young subsidizing the old). Other subsidies are likely less tolerable and give rise to the opportunity for hyperbole (e.g., the young, healthy nonsmoker who is forced to subsidize the couch potato who lives on a diet of chocolate milk and potato chips). And while the latter example might be unlikely and overdramatized, such contrasts clearly reverberate with the public and make it difficult to pass any legislation with a mandate.

In the abstract, you could see how these sorts of mandated wealth transfers could be used as a justification for paternalistic policies to improve public health. For example, because the state requires nonsmokers to subsidize care for smokers, perhaps the state should also have a stronger right to ban smoking. Going further, perhaps because nonhang-gliders are required to subsidize the setting of the broken bones of actual hang-gliders, the state has a right to limit our right to participation in dangerous activities.

However, while I see the how mandates and universal health care could prompt cries for more aggressive public health interventions, I don’t see how that position is particularly well justified. For starters, just because a government (in this case the British government) has acted in one sphere of public policy, it does not implicitly give them a right to operate in another. Regulating health insurance or health care provision is a remarkably different activity from regulating individual behavior. Applied to the case of driving, even if the government requires individuals to carry auto insurance or pass a drivers’ exam, the government does not explicitly have a right to require drivers to keep their reflexes sharp so that they’re better drivers. In the case of public health, government action may be required and justified if there are clear failures of information that lead individuals to make decisions they would not have made were they fully informed. However, the justifications for those types of interventions have little to do with how health insurance markets or health care delivery systems are structured. They are in fact, separate, though equally important issues.

Second, and more importantly, it’s not entirely clear that requiring individuals to live healthy lives would actually reduce government health care spending. Indeed, recent evidence from the Netherlands suggests that it could actually increase it. In a 2008 study published in the Public Library of Science – Medicine Journal, van Baal et al. estimated that although reducing obesity led to lower levels of spending on obesity-related diseases, in the long term this was offset by additional spending required during the life years gained. This isn’t a particularly surprising result. Good public health has allowed people to live longer; in turn, this required higher levels of aggregate spending.

Third, these sorts of questions assume that the person who’s smoking, hang-gliding, or eating a ridiculous diet is free riding off the system without any consequences for his or her actions. In fact, there are all sorts of consequences. As a direct result of activity, these people will likely live shorter lives. The case of a person jumping a subway turnstile and using public transport for free is not analogous to the person who smokes, gets cancer, and then requires subsidized health care. In the former case, the person is getting something for free; in the latter case, the person is getting a subsidy but clearly paying a price in the form of pain and suffering. Along these lines, policymakers in the U.K. have enacted sensible tobacco policies whereby the tax revenue garnered from the sale of cigarettes goes directly toward treatment of smoking-related illness. These kinds of tax changes can help governments maintain sensible wealth transfers while assuaging fears of seemingly inappropriate subsidies.

In the long run, health care spending is growing at an alarming rate in most countries, and action clearly needs to be taken. Some of our high health care spending is driven by inefficiencies within health care systems; other drivers emanate from our individual behavior. We very much need to address the market failures in the health insurance market that give rise to high costs and gaps in insurance coverage. We need to take steps to improve the way that health care is delivered so that so much care is not wasted, as is too often the case. And we need to invest in public health to help individuals have every opportunity to live a healthy life.

But we also need to realize that interventions in one sphere cannot be driven by pathologies in another sphere. It is vital to address public health, but the arguments for addressing public health failures and challenges are quite distinct from the arguments for expanding health insurance coverage. We need to address both challenges, but we need to do so for the right reasons and be conscious of some of the pervasive tensions between individual liberty and policy interventions to improve public health.


Special Contributor Zack Cooper is a research officer with the London School of Economics. His monthly column for the Health Policy Forum considers health policy from the international perspective. “Special Contributors” are regular contributors to the Health Policy Forum who pose their own opinions and policy positions in the realm of health care and health policy. As a leading nonprofit health care research and consulting institute dedicated to improving human health, Altarum encourages open discussion and debate about the many challenges in health care today. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions. Read more.

One Response to Does Mandated Insurance Mean More Paternalistic Public Health Policy? Hopefully Not.

  1. Michael Parkinson, MD, MPH, FACPM

    Another perspective. With highest health care costs in world with majority (likely 75%) related to chronic disease directly related to personal and community “unhealthy behaviors”, yes, we better energize public health to prevent further runaway costs now that everyone has “insurance”.

    Where and how we live, learn, work and play are a greater determinant of our health than health care. The government (any government) isn’t being “paternalistic” – they’re being “patronizing” not showing citizens the true and direct costs that they control – and the opportunity costs of money NOT spent on things that they may value more (education, transportation, higher salaries, more jobs etc).

    Ironically a good “parent” doesn’t sugarcoat reality. They insist that children grow up and understand the real value of resources and choices. I WISH our government was more truly paternalistic – viz insisting that the real prices and options we as consumers and patients have – rather than patronizing assuming that someone besides “us” is going to make health (insurance) reform both affordable and sustainable.

    Only by reducing the “demand” for care (91% of diabetes, 80% of heart disease, 60% of all CA’s for example) thru improved personal and community behaviors and the “non-medical” determinants of health – yes, by leveraging public health and private sector innovation – can we ever hope to make a dent in the “supply side” medical-industrial complex.

    US employers are leading the way as they see the true bottom line costs (3X medical costs) – and yes, you will and should pay more for health insurance based on willingess to participate and in some cases, even demonstrate “progress to target”. While some have perhaps gone a bit too far too soon, they all feel that to do less, is not only wrong, but patronizing. By creating their own “culture of health” rather than “culture of illlness with insurance coverage”, they’re often the sparks to energize surrounding communities to ask “why have we been so passive”? Indeed some employers have in a sense, created a model of “public health with teeth” for their employees and families – and perhaps we can all learn how best to move forward together!

Leave a Comment

(In order to leave a comment, you must supply information for all of the required fields below)


Note: Comments are subject to approval and moderation. Please keep your thoughts brief and avoid ALL CAPS. Thanks for joining the conversation.

Health Economist, London School of Economics