By Tim Bonfield
The Cincinnati Enquirer
Call it high-risk health insurance. Call it a healthy living discount.
Whatever it's called, the idea of making people who lead unhealthy lifestyles pay more for health insurance is a good one, most Greater Cincinnati residents say.
More than half of people who answered an Enquirer survey in January said that smokers, fat people and those who don't take good care of themselves should pay more for health benefits. It's a blame-the-sick attitude that reflects rising frustrations over the soaring costs of health care.
Cost concerns outweigh all other health worries 2-to-1, the survey of 624 adults in seven Ohio and Kentucky counties shows. Nearly 57 percent say the region's health-care system is in a "crisis" - not because quality care is lacking, but because people fear they can't afford it.
Increasingly, here as elsewhere, people in good shape are becoming critical of those who aren't.
Susan Conway, 46, of Terrace Park works out at the Cincinnati Sports Mall and encourages her children to be athletic.
When she looks at how others live, she wonders how much of the ever-rising premiums her family pays for health insurance subsidizes unhealthy lifestyles.
"The system is hugely expensive. And there are no rewards for staying healthy," she says. "We pay just as much as people who smoke or eat anything they want."
Brian Beldon, 36, of Hyde Park works out five days a week on weight machines and treadmills. "I don't think unhealthy people should pay more than they pay now. But I do think people who are willing to put in the time and effort to stay in shape should get a discount versus people who could care less," he says.
The idea of charging more for risky behavior is well grounded in American insurance practice. Auto insurers charge more for reckless and drunk drivers, and insurers offer good-driver discounts as well. Life insurers routinely adjust their rates - or refuse to offer coverage - based on factors like smoking, age, dangerous occupations and medical history.
But the notion of charging more for risky living is controversial when applied to health care coverage.
With rare exceptions, corporate and government health plans do not charge extra to obese people, smokers or those who engage in unhealthy behaviors. Nor do many plans offer anything beyond a token discount for safe and healthy living.
"Once you go down this road, you get into huge value judgments about whose lifestyle is better than another's," says Dr. Robert Berenson, a senior fellow at the Urban Institute's Health Policy Center in Washington, D.C.
"Somebody would have to decide which habits are desirable and which are not. Who would that be?"
There is no debate that unhealthy lifestyles contribute to the rising costs of health care in America. And unhealthy lifestyles abound in Greater Cincinnati.
Just take a look around. Knots of smokers huddle outside many buildings. Ten people were smoking in a designated area outside Cincinnati Children's Hospital Medical Center on March 31, within sight of a row of kid-produced posters honoring "Kick Butts Day."
None of the smokers thought it would be fair to charge them more for health benefits because of their habit. Many smokers resent the restrictions they already face.
"It's like you're no longer living in a free world," says Debbie Howard, 45, of Dayton, Ohio, who was catching a smoke during a visit to the hospital. "It's like they're controlling your life instead of you controlling your life."
About 33 percent of adults are smokers in 14 Ohio, Kentucky and Indiana counties around Cincinnati. That's well above the national average of 23 percent, according to the Health Improvement Collaborative of Greater Cincinnati.
Someday, some of those people will rack up health care bills from heart disease, stroke, emphysema, lung cancer and seven other cancers linked to smoking.
Stroll through any ballpark, amusement park or festival and you'll see crowds of obese people, too.
That woman may end up on kidney dialysis from diabetes caused by excess weight. That man may have a heart attack. That child may face colon cancer, another illness with links to bad diet and lack of exercise.
More than 58 percent of people in the 14 nearby counties are overweight or obese, according to the Health Collaborative. That's about the same as the U.S. average of 59 percent - but the rate of obesity has spiked in recent years.
In 1991, obese people made up more than 15 percent of the population in only four states, according to the Centers for Disease Control and Prevention. By 1998, that figure had leaped to 40 states - including Ohio, Kentucky and Indiana. By 2002, all 50 states were above the 15 percent mark.
Obesity is defined as having a body mass index of 30 or more, a measure that combines a person's weight and height.
Public health officials now say that obesity threatens to overtake tobacco as the nation's leading cause of preventable death - with each problem contributing to 300,000 to 400,000 deaths a year.
Be it increased tax spending for Medicare and Medicaid or bigger paycheck deductions for private health benefits, we all wind up paying the bill for unhealthy living.
Michelle Caldwell leads a step aerobics class at Health Alliance.
(Meggan Booker photo)
The rising obesity trends have prompted a chorus of cheerleaders for self-control - from federal health secretary Tommy Thompson, who recently visited Cincinnati to talk about the growing scourge of diabetes, to Ahron Leichtman, 61, of Amberley Village, who has the disease.
Thompson visited Cincinnati on March 29 as part of a series of town meetings about diabetes, the nation's sixth leading cause of death. He said rising cases of Type II diabetes can be slowed if people do more to eat right and exercise.
"This is a serious problem facing our nation and a problem that if we don't do something about, it's only going to get worse," Thompson said.
Leichtman controls his Type II diabetes through strict diet, exercise and medications. He doesn't see why he should pay as much for health benefits as the person who doesn't control his disease.
Leichtman was shocked to see his monthly premiums for single coverage jump from $424 last year to $630 this year to a proposed $888 for next year. As the owner of a small media relations business, he buys his health insurance through the Greater Cincinnati Chamber of Commerce.
"It blows my mind," Leichtman says. "During the next four years (until he qualifies for Medicare), I figure I'll have to pay more than $40,000 for insurance, probably $50,000 by the time you add in all the deductibles and co-payments."
Some experts say people who take unnecessary risks should pay more.
"Why are we letting children ride bikes without helmets? All you have to do is take one look at the data on head injuries from Children's Hospital," says Lynn Olman, president of the Greater Cincinnati Health Council.
"I go nuts when I see people who don't wear seat belts," she says. "We all pay if that person has an accident. Should people have to pay more if they don't wear seat belts? I think so."
Where does it stop?
Others, though, raise hard questions about charging unhealthy people more for health coverage.
Anton Peens, 40, of Independence, KY, smokes a pipe.
(Meggan Booker photo)
"I don't think we can go very far in that direction," says the Urban Institute's Berenson, a former high-level administrator for the federal Health Care Financing Administration.
"People who are obese already suffer health problems and social stigma. I don't think we really want the health police coming to work and putting people on scales."
Some people are overweight because of metabolic or genetic conditions beyond their control. Others may not be able to afford healthier foods, or they may feel unsafe exercising in their neighborhoods.
"There's probably 40 percent of society who can't afford a basic membership at the Y and probably don't have a good idea about nutritional food," says Kathy Cox, 56, of Pleasant Ridge.
Michelle Caldwell, 39, of Milford teaches step aerobic classes for employees of the Health Alliance of Greater Cincinnati. She says it would be unfair to charge people more for being obese.
"That's just labeling people incorrectly," Caldwell says. "You can be a thin person and wake up the next day with cancer. And you can be obese and healthy. There are obese people who don't have high blood pressure or high blood sugars."
The bigger question with high-risk health insurance is: Where would the health police stop?
Should people pay higher medical bills if they play high-risk sports or get hurt in hazardous activities such as skiing, skateboarding, rock-climbing or skydiving?
Should people battling AIDS pay higher doctor fees if they contracted the disease by having unprotected sex or sharing tainted needles?
"What about the guy who goes on a drinking binge every weekend?" says Dennis Olver, 59, of Hebron, Ky., a regular smoker. "If you're going to charge people for one bad habit, you should do all of them. All of them or none of them."
Berenson says the whole purpose of health insurance is to spread the risk around, making it affordable to all.
"Most of the people who are healthy most of the time subsidize the care for the few people who get sick at any one time," he says. "If you atomize the system by creating individual health risk profiles, the next step will be genetic screening. I don't think we want to go there."
The great hope for genetic screening is that doctors can catch conditions early, when they can be controlled or prevented, allowing people to live longer, healthier lives.
The great fear is that genetic profiles might be used to deny insurance to those most at risk of developing breast cancer, Alzheimer's disease or other conditions.
Some laws already have been passed to prevent insurers and employers from using genetic information in discriminatory ways. But since the field is so new, the strength of those laws remains largely untested, Berenson says.
To a certain extent, those who lead unhealthy lifestyles already pay more for their health bills, says Alwyn Cassil, a spokeswoman for the Center for Studying Health System Change.
Many employers are charging workers higher deductibles for coverage and higher co-payments when services are used. As a result, people who don't take care of themselves will wind up devoting more of their income to health care because they are more likely to need a doctor or a hospital.
Your views on health
The Enquirer wants to hear your ideas and experiences with the health care system. Please send comments to Tim Bonfield, health issues reporter, The Cincinnati Enquirer, 312 Elm St., Cincinnati OH 45202. Or fax to (513) 768-8340. Or e-mail email@example.com.
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