Don’t tax the fat!
Dr Philip Lee, Conservative MP for Bracknell and a practising GP, today suggested that people whose lifestyle choices lead to medical problems should have to contribute towards their healthcare costs. He apparently highlighted type 2 diabetes – which can be brought on by an unhealthy diet, being overweight, and lack of exercise, although some people are genetically disposed to it – and is quoted in the Huffington Post as saying, ‘If you want to have doughnuts for breakfast, lunch and dinner, fine, but there’s a cost’.
At first glance, the idea that those who lead unhealthy lifestyles should bear the burden of their own resulting health problems seems fair. But there are serious problems with this idea. Let us consider two of them.
First, it seems likely that this sort of policy is not merely about penalising people for unhealthy lifestyle choices. Dr Lee’s comment about doughnuts and diabetes suggests that he is targeting fat, lazy people with a cavalier attitude towards their own health. Discussions of this sort of policy also often highlight (as the Huffington Post article does) the cost of treating the health problems of smokers and heavy drinkers. But it is not only fat people, smokers, and heavy drinkers whose lifestyles end up costing the NHS money. People often suffer health problems as a result of leading lifestyles that we do not normally think of as being unhealthy: sporty people are at an increased risk of suffering joint problems, computer users of eye strain, outdoorsy people of skin cancer, drivers of injuries in car accidents, and so on. If a policy of making people pay for healthcare necessitated by their lifestyle choices is to be fair, we must ensure that we target Olympic gold medallists with knee injuries just as heavily as we target doughnut-guzzling smokers with diabetes. If we do not, such a policy could end up as a surreptitious tax on people with the sort of lifestyles that society frowns upon. This would be a sinister and worrying outcome. We might celebrate those who win Olympic gold medals over those who sit at home with a fag and a doughnut, but financially penalising people for doing the latter amounts to a curtailment of freedom that is unacceptable in a society that aspires to liberal values.
Second, whilst Dr Lee’s suggestion is intended to save the NHS money, it could end up doing the reverse. How is it to be determined to what extent a patient’s lifestyle is responsible for her health problems? Whatever the method, it is likely to involve a significant amount of time and effort – and therefore expense – spent information-gathering, consulting, discussing, and evaluating. Perhaps it might require even more sophisticated and expensive processes: some people, after all, may be genetically disposed to diabetes, lung cancer, or liver disease. It would be unfair to penalise such people for their health problems, even if they are fat, smoking, alcoholics. So it might become necessary to screen people for such genetic predispositions before concluding that their health problems are caused by their lifestyles. This burden on the NHS is likely to grow as medical understanding of various diseases advances: every new factor that is identified as contributing to a disease is another factor that must be taken into account when evaluating the extent to which a patient is responsible for the fact that she suffers from that disease.
The idea that those who cost the NHS the most should be made to contribute the most is intuitively appealing. But a policy that attempts to enforce it risks being unacceptably paternalistic and counter-productive. This does not entail that such a policy could never be made to work. If such a policy was transparent about what it aimed to achieve, perhaps it could be workable, cost-effective, and even an incentive for people to lead healthier lifestyles. For example, the government might introduce a policy that all smokers who suffer respiratory problems will be made to contribute towards the cost of their treatment, regardless of whether or not they are genetically disposed to such problems. It could do so without representing the policy as part of a general campaign against those whose lifestyles cost the NHS money – a campaign which, in fairness, should also target athletes and the like. Such a policy may be controversial, but it is not obviously any more unfair than the taxes already levied on tobacco. Even so, it would perhaps be difficult to avoid such a policy being represented by the media as part of a general ‘make the unhealthy pay’ campaign.