A few years ago, the National Health Service (NHS) first considered refusing to treat obese people for lifestyle-related illnesses. In the same vein, the National Institute for Health and Clinical Excellence (NICE), the NHS's guidance body, produced advice that raised the prospect of heavy smokers and obese people being refused healthcare. But that will never happen, many said.
Well, it already has. Discriminatory healthcare is the new reality.
An NHS health trust now proposes to stop sending obese people and smokers for certain operations. NHS North Yorkshire and York is planning to stop patients who smoke, and those with a body mass index of more than 35, from having routine hip and knee surgeries because their unhealthy lifestyles allegedly lower the chance of the operations' "success."
Clare Gerada, chair of the Royal College of General Practitioners, said "these [policies] are being introduced because of financial constraints. I am concerned that in one part of the country smokers and the obese won't get this surgery. I'd like to see the evidence." As would we.
The first problem with this discriminatory policy is that preventing morbid obesity and smoking can save lives but it does not save money. For a very long time, economists have known – but comparatively few have dared to publicise the fact – that smoking and smokers are good for the public treasury, if not for public health. Recently, economic research has shown that the morbidly obese are also net contributors to the Exchequer.
The truth is that it costs more to care for healthy people who live years longer. This economic fact was confirmed two years ago in a rigorous study funded by the Dutch Ministry of Health, Welfare and Sports and published in the Public Library of Science Medicine journal. A research team led by Pieter van Baal, an economist at the Netherlands' National Institute for Public Health and the Environment, found that the health costs of thin and healthy people in adulthood are more expensive than those of either fat people or smokers.
Van Baal and his colleagues estimated lifetime health costs for three groups of 1,000 people: the "healthy-living" group (thin and non-smoking), obese people, and smokers. The researchers found that from age 20 to 56, obese people racked up the most expensive health costs. But because both the smokers and the obese people died sooner than the healthy group, it cost less to treat them in the long run.
On average, healthy people lived 84 years. Smokers lived about 77 years, and obese people lived about 80 years. Smokers and obese people tended to have more heart disease than the healthy people. Cancer incidence (except for lung cancer) was the same in all three groups. Obese people had the most diabetes, and healthy people had the most strokes. Ultimately, the thin and healthy group cost the most, about $417,000 (£257,000), from age 20 onwards. The cost of care for obese people was $371,000 (£228,000), and for smokers it was $326,000 (£201,000).
This study is but the latest to throw a bucket of cold water on to the idea that preventing smoking will save governments huge sums. Thirteen years ago, Cato Institute economist Peter Van Doren informed us that "the premise that non-smokers subsidise smokers just isn't true." He presented Kip Viscusi of Harvard's calculations that smokers create savings for taxpayers that usually are not considered.
Because smokers die earlier than non-smokers, taxpayers save expenditures that otherwise would be made for pensions, as well as nursing home care and other costs related to conditions associated with old age. Those savings more than offset the costs that smokers create. American smokers actually save society about $.32 (20 pence) per pack of cigarettes smoked.
Other researchers, such as economists Jane Gravelle and Denis Zimmerman, have also found that American smokers contribute many more times to public coffers than they withdraw. Furthermore, Van Doren explained that if every smoker quit today, healthcare costs would drop in the short run and then climb higher in two or three decades because of the increased life span of ex-smokers.
Several Canadian economists had earlier calculated the benefits to non-smokers and costs to smokers. The University of Montreal's André Raynauld and Jean-Pierre Vidal estimated that in 1986 Canadian smokers paid more in tobacco taxes than they cost the country's healthcare system – that is, smokers paid a $363 (£230) subsidy to each non-smoker in the country. Previously, Greg Stoddart and his colleagues found that in 1978 smokers in the province of Ontario cost government between $21.5 (£13.6) million and $39.1 (£24.7) million but paid $485 (£307) million in taxes; that is, smokers paid in taxes between 22.2 and 12.3 times what they cost the system.
The second problem with this discriminatory policy is that it is an illegitimate function of the state to penalise individuals for unhealthy behaviour.
For centuries, economists and philosophers have pondered the principles of "just" taxation. The debate on the correct level of taxation for tobacco products continues, as well as for other lifestyle products, such as fast food, which may become aggressively taxed by the state as a means of coercing individuals' behaviour. The logic behind high taxation on these products is to inflate the retail price to reduce their availability and drive down consumption.
This means that individuals who choose to smoke, for example, pay more to support government services than those who choose not to indulge in this behaviour. This normally prompts the response that consumers of tobacco are far more likely to require treatment by the NHS. However, as we have already established, the cost of treating all smoking-related illnesses is greatly exceeded by the volume of revenue collected by the Treasury in taxation from tobacco.
Smokers and others who indulge in risky behaviour are taxed at a disproportionate level to those who choose not to engage in such activities. However, these same groups of people – in particular smokers – are now liable to be refused some treatments in hospital, including surgery, as a result of their unhealthy habit, as well as some treatments unrelated to their habit.
Such discrimination on the grounds of lifestyle is illiberal and encroaches on individual rights, and is arguably beyond the legitimate function of the state. Refusing medical treatment to an individual who not only requires it but who has has financially contributed more than the average to its funding, as a means of coercing him or her toward healthier behaviour, is undemocratic and borders on tyranny.
Most people would agree that it is unethical to refuse to treat a medical ailment on the grounds of preventative health, and arguably sets a dangerous precedent signalling a system of rationalised healthcare, where treatment could be refused to the elderly or to babies born with serious health problems. Ironically, this public health prescription neglects the World Health Organisation's definition of health – "health is the mental, physical and social wellbeing, not merely the absence of disease or infirmity" – by ignoring the social wellbeing of the individual.
The bottom line is that government projections about smoking and obesity costs are frequently based on guesswork, political agendas and changing science. Therefore, if we are going to worry about these problems, we should stop worrying about their financial impact.