Finally Imposing Personal Responsibility Could Save Taxpayers Trillions

WASHINGTON, D.C.  (October 22, 2018) – A massive new study by the Cleveland Clinic showing that failure to get enough regular aerobic exercise, as measured by a simple treadmill stress test, can be more dangerous to one’s health than smoking, high blood pressure, or being diabetic could encourage health insurance companies to impose a surcharge on those who refuse to exercise, just as they long have with regard to people who smoke, says public interest law professor John Banzhaf, “Mr. Anti-Smoking.”

Banzhaf first proposed so-called differential health insurance premiums in the 1980s, helped persuade the National Association of Insurance Commissioners [NAIC] to endorse the concept, obtained rulings from the federal government permitting health insurance to charge smokers much higher health insurance premiums, and helped persuade Congress to include a 50% surcharge on smokers under Obamacare.

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With the Affordable Care Act's [ACA] prohibition on refusing to provide health insurance (or charging higher rates) for people with pre-existing conditions under challenge in the courts, as well as by some members of Congress, this important new study might provide an additional incentive and justification for insurance companies to impose surcharges on those who not only smoke, but also on those who refuse to get enough of the aerobic type of exercise which this study shows slashes health risks, argues Banzhaf.

The American Lung Association estimates that smoking costs the American economy over $300 billion a year, even though only a tiny fraction of the adult population smokes.

So, if the study shows that inadequate cardiovascular exercise is even more dangerous than smoking - at least in terms of mortality, which correlates with medical care costs - and involves a much larger percentage of the population (only 23% of Americans get enough exercise - CDC), requiring those who smoke and/or get insufficient cardiovascular exercise to pay for the huge unnecessary additional medical costs they now impose on others could save many trillions of dollars over a traditional ten-year measuring period.

Finally, imposing widespread personal responsibility for individual health-related decisions such as smoking and exercise, which is something both Republicans and Democrats insisted was necessary to slow ever escalating health-care costs, is much fairer than the ACA approach which largely simply shifts the costs from unhealthy (largely older) populations to healthy (largely younger) ones.

It is also better than again permitting insurance companies to charge insured more because of pre-existing conditions, much less to refuse to insure them at all.

Refusing to insure someone once he has been diagnosed with lung cancer, or charging him far more to cover the enormous costs of treating this condition, may seem unfair, but charging him more before he gets lung cancer because he smokes (which causes most lung cancers) seems more reasonable, especially since it is likely to provide a strong added incentive for him to quit, and thereby save everyone money.

For example, we know from many studies that even small incremental increases in the cost of being a smoker - e.g., increases in the per-pack tax on cigarettes - clearly have a significant impact on helping the overwhelming majority of smokers who already want to quit to do so.

Moreover, as the Wall Street Journal and the British Medical Journal have reported, imposing a smoker surcharge can slash smoking rates among employees by 50%.

Likewise, refusing to insure someone who has suffered a heart attack or stroke, or charging him far more to cover the enormous costs of caring for him once it occurs, may seem unfair, but charging him more before he gets a heart attack or stroke because he refused to perform enough exercise to reduce his risk seems preferable, and likely to encourage more people to get sufficient aerobic exercise.

Charging smokers more for health insurance - as companies have long done for life insurance, and in some instances for home or automobile insurance - is not difficult, since most applicants will readily admit on application forms if they are smokers; especially since they fear that lying may void their coverage, and it is difficult to completely conceal one's smoking habit from friends and co-workers.

Charging more based upon physical fitness assessments is not as straightforward, since it requires some kind of testing for cardiorespiratory fitness.

But exercise treadmill testing [ETT] is increasingly being used as an important component of comprehensive medical exams, and sometimes is even provided to persons joining gymnasiums or other fitness centers.  For example, the Cooper Fitness Center is Dallas has long administered a treadmill (or similar stationary cycle) stress test to those who join.

Moreover, whatever the expenses of such tests, the costs are almost certainly far lower than the cost savings physically fit applicants can qualify for in medical insurance premiums.

Also, many argue that the savings from treadmill testing, in terms of screening for and helping to prevent cardiovascular events such as heart attacks and strokes, would be much greater than the cost of the tests, even without the savings from lower cost health insurance.

Now that the huge medical risks of being unfit have been more firmly established, researchers may be strongly encouraged to see if there are easier and less expensive ways of objectively measuring cardiorespiratory fitness to provide the justification necessary to avoid an insurance "lazy" surcharge.

For example, many have used the timed-run test, where subjects are timed while running 1+1/2 miles (or some other distance), as a good measuring too, with appropriate adjustments for age and gender.

It's much less expensive, since dozens if not hundreds of subjects can be timed with a stopwatch in a mass event as they run around a high school, college, or other running track.

Another alternative to a treadmill stress test or timed-run test might be to measure resting pulse rate [RPR], which seems to be well correlated with cardiorespiratory fitness.

Increasingly, fitness wrist watches/monitors help users determine their own RPR, and it could easily be validated - to qualify for lower health insurance rates - by independent third parties such a doctors.

If smoking costs our economy over $300 billion a year, and refusal to exercise costs even more, we can no longer ignore them, and rely largely on public health messages to reduce them.

Rather than continuing to force those who do exercise and don't smoke and to bear these enormous unnecessary costs, it's time to impose some personal responsibility, argues Banzhaf.