Buying Better Behavior

By Martin Harris

Martin Harris

People who study how language evolves (or not, as in the French resistance to the despised American word “hamburger”) might be called “linguisticians” except for the fact that the word hasn’t yet been invented and accepted. President Eisenhower, the elderly fraction of this readership will recall, was serially denounced by the superior-intellect Left for his invention of the verb “to finalize”, while their own recent invention of the verb “to Google” has gone, of course, unchallenged, so it’s OK for your Humble Scribe to use it here. Google the phrase “user fees versus taxes”; you get about 1.4 million entries, which don’t prove much except that it’s an old argument and, in general, those of Conservative persuasion prefer voluntary user fees to pay for such government services as, say, public highways; and Liberals prefer to mandatory-tax everybody, service-user or not, so that those who use the road can do so “free”. Like the planned-economy versus the free marketplace, it’s one of those Left-versus-Right divides so simple even a columnist can understand it. Where your Humble Scribe comes to intellectual grief is (are?) those multiple instances wherein the Left wants both simultaneously. Cases in point: Liberal enthusiasm for higher user fees on cigarette purchases and the promised reward for thrifty-power-user behavior implicit in the Smart Meter initiative, in apparent opposition (I adjective-ize with “apparent” because maybe there’s a hidden sophisticated concept, too nuanced by far for a mere Scribe to appreciate it, buried therein) to any health-care-insurance design containing any sort of monetary incentive for measurable life-style behaviors which are recognized as healthful. Like no-tobacco-use, or not getting too fat.

There are a few States which have designed and implemented health-care-insurance programs with modestly lower premiums for enrollees who agree to behave better for money, but these are -take North Carolina as an example– quite modest in scope, apparently because of the fear of Federal legal intervention should anything significant be tried. Municipal employees in NC, for example, can earn points by attending wellness classes. What each “point” is worth, premium-wise, was beyond the ability of a mere Scribe to figure out. It seems that it’s not much. In general, governments are enthusiastic for taxing everyone, on the theory that everyone eventually gets sick, and the private sector is enthusiastic for incentives, which are simply user-fees in negative dollar terms as rewards for measurably healthful behaviors (like The Safeway Plan, discussed in earlier columns in this space) which promise, probability-wise-that the suitably skinny non-smokers will cost the system less for health care than those who puff and eat too much. These uncomfortable epidemiological facts are reflected in a just-published American Cancer Society study, showing that better-educated people practice better health behaviors than lesser-educated people, and contract cancer less frequently. Here’s a quote: “Indeed, 31% of men with 12 or fewer years of education are current smokers, compared to 12% of college graduates and 5% of those with a graduate degree. The lung-cancer death rate is five times higher in the least-educated than in the most.”

By various measures, Vermont’s population is one of the best educated. The StateMaster website, using a quite complex set of factors, rates VT as #1 nationally. It rates TN as #41. Similarly, VT ranks well (pun intended) health-wise with percent-who-smoke at #39, while TN ranks #5. The chart is on MedScape.com. As you’d expect, therefore, the “lung-and-bronchus”‘ cancer incidence in VT is 9.2 per 100,000 male, 5.7 female, and in TN the numbers are marginally (5 and 9 percent) higher: 9.7 male, 6.2 female. See the ACS website for the full chart.

Question: which State should consider monetary incentives for insurance-buyers to kick the habit and save their neighbors on taxes? One could argue that a VT response to an education-with-reward effort would work better than in TN, but then TN, with a population 10 times that of VT, could reach more people, change more behaviors, and, save more health-care money. There’s more: VT’s governance is ideologically hostile to incentives (for insurance, but not for actual smoking-deterrence) while TN’s is ideologically receptive. It’s the blue-state/red-state thing, and, interestingly, it’s not too far back that both States’ voters were differently minded, with a Republican VT and a Democrat TN. Presently, VT hasn’t yet had enough adverse experience with ShumlinCare to be seeking options like incentives, but TN has had enough painful experience with TennCare to be much more open to the buying-better-behavior concept. Overall, VT, with already-in-place low rates of behavior-based illness, has less to gain from attempting to change citizen behavior with education and incentive, while, conversely, TN has more to gain but a more difficult customer-group to engage and motivate. And, voters in VT clearly have no objection to sin-taxes (user-fees/ negative-incentives) on tobacco, to avoid broad-based taxes to pay for the inevitable cancer-care, while voters in TN are clearly opposed, a new survey reports, to sin-taxes on junk-food, and therefore, apparently, must prefer the inevitable broad-based taxes to pay for the inevitable diabetes and heart-disease care.

Scribe confession: I’m a fan of Progressive SCOTUS Justice Louis Brandeis. That’s for his (approximate) quote:”States should be laboratories for democracy”. I’d like to see each State try one alternative, and, if Scribes are permitted druthers, I’d like to see what actually happens in actual fiscal results when VT goes without incentives and TN goes with them, in accordance with Scribal estimates of the present political propensity in each State, as reflected by the resident population under the Golden Dome in Montpelier and under the Marble Cupola in Nashville. A part of that policy-preference for my adopted State is reflected in that other Brandeis (approximate) quote: “every citizen has a right to be left alone by his government”, and voluntary incentives or user fees for some (no use, no pay) are closer to that goal than mandatory-taxes on all.

 

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