Young Economist 2017 winner: Louise Averill
01 Oct 2017
“If you don't look after your health, you can't expect free access to healthcare”. Is this wrong? What are the economic arguments?
In June 2009, researchers from Oxford University’s Department of Public Health released a paper entitled ‘The burden of smoking-related ill health in the UK’. Prior to its publication, official estimates for the annual cost to the NHS of smoking-related illnesses ranged between £1.4-1.7 billion. However, the new research suggested an enormous £5.2 billion per year was spent by the NHS on surgery and other treatments directly related to smoking (S. Allender et al, 2009).
In November 2014, the McKinsey Global Institute published an essay estimating that obesity and obesity-related illnesses, including type 2 diabetes, cost the NHS £6 billion in 2014, estimated to rise to around £8 billion in 2017 (R. Dobbs et al, 2014). These two figures add up to around 10% of the NHS’s total budget of £122.6 billion for 2016/17. To someone who, like many of the population, sees both smoking and obesity as easily preventable given a little willpower and common sense, this figure appears a ludicrous waste of resources. The NHS is currently suffering a crisis so severe that 96% of hospitals do not meet their own ‘safe staffing’ requirements (S. Lintern, 2017), with extreme overcrowding and understaffing causing wait times for surgery and medical attention to increase to dangerous levels. It’s easy to argue that those who willingly and knowingly endanger their own health don’t deserve free healthcare, when it’s at the expense of those with non-preventable illnesses.
Public health campaigns such as the popular ‘Change 4 Life’ ensure that both adults and children are fully knowledgeable about how to eat a healthy diet, and free NHS ‘Smokefree’ kits provide smokers with all the resources and support they need to quit. In a society where living healthily may be an easy and affordable choice, it’s easy to see how unjust funding others’ unhealthy lifestyles may be seen. For example, there’s an enormous shortage of organ donors. Most would agree that allocating a donated liver to someone with a non self-inflicted liver disease, as opposed to an alcoholic who voluntarily destroyed their own liver, would be more just. Furthermore, it would be a more efficient allocation of resources. The alcoholic is more likely to damage the donated liver, leading to further health complications, therefore fewer high quality years of life (and years of productivity) are gained from the transplant.
According to some statistics, if severe restrictions were placed on free treatments for obesity and smoking- related illnesses, the NHS would have an extra £10 billion a year to spend on doctors, drugs, treatments and beds, meaning the quality of care received by other patients would undoubtedly increase. There’s also an argument that the NHS is a prime example of the tragedy of the commons. When healthcare is free – or seen to be free by consumers – people are more inclined to abuse the system: booking unnecessary doctors’ appointments; requesting unneeded prescriptions, or simply neglecting their own health with the mentality that someone else will pick up the bill for any expensive surgeries this neglect will incur.
For this reason, it seems logical that restricting healthcare access to smokers, obese patients, drug addicts and alcoholics will in the long-term, not only save the NHS money but also reduce the prevalence of these problems in our society. The threat of severe financial loss may be a more effective motivator than the threat of health complications. In fact, some NHS practices have already taken a small step in the direction of restricted healthcare access for the obese. Since 2011, GP surgeries in Hertfordshire have been requiring patients with a BMI of above 30 to lose weight – in severe cases, up to 30 pounds – before they are given non-urgent knee and hip joint surgery (R. Smith, 2012).
The reason for this was quoted on an official NHS website as being “because obese patients have much poorer outcomes from surgery…a key strand of our overall strategy on healthcare is helping people to live healthily” (“Hitting the headlines...”, 2016). And following NHS overspending to the tune of £2.45 billion in 2015-2016, more practices are adopting similar requirements as part of nationwide “rationing” of finite treatments. However, the solution isn’t that simple. From an ethical perspective, there are obvious issues with control over who is ‘allowed’ free healthcare and who isn’t. In 1946, the World Health Organisation argued “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being”, a statement at odds with the idea that healthcare access should be controlled by the government. The concept in some ways feels like a move towards totalitarianism; the legal right to restrict healthcare to certain groups could easily be abused for individual or bureaucratic gain.
Equality and democracy is at the heart of the UK; in a society where even criminals are given free healthcare, it seems perverse to refuse the same right to law-abiding, tax-paying citizens. In actual fact, the root causes of obesity and substance addiction need to be addressed in order to hold the argument that unhealthiness is entirely self-inflicted. It’s estimated that nearly 40% of smokers have a mental illness (“Smoking and Mental Illness...”, 2017), indicating that addiction to nicotine can be a much more complex issue than a lack of willpower.
Almost half of overweight adults were overweight as children (F. Lifshitz, 2008), so it could be argued that the problem of severe obesity begins at a stage where the individual is not intellectually capable of making their own decisions about their diet and exercise. The age of criminal responsibility - beyond which children are considered capable of independent rational thought – is 10, however according to current governmental statistics, 22% of 4-5 year olds are overweight or obese (C. Baker, 2017), indicating the problem starts much earlier than this. Furthermore, food addiction has been recognised as a mental illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) since 2013, offering an argument that many obese people cannot be held entirely responsible for their own health, any more than an anorexic patient can. Of course, there are many obese patients who could easily become healthy with a rigorous diet and exercise program.
However, separating those with a genuine food addiction from those who just have poor willpower would be logistically difficult and undoubtedly time-consuming and costly. Furthermore, the wider logistics of implementing a restricted healthcare access policy would be almost impossible to work around. Most obesity and smoking-related illnesses are also common within the general ‘healthy’ population, so there would have to be some system of ‘background checks’ to ensure a patient is non-smoking before they are given surgery, for example, or a ‘maximum weight’ above which treatment is no longer given, which may incur more costs for the NHS.
On top of this, this essay has mostly explored the implications of smoking and obesity, as these are the two main cost burdens on the NHS often considered to be easily preventable. However, if free healthcare access is restricted only to those who may be reasonably assumed to take care of their own health, it could be argued that many, many more treatments should also be restricted. For example, injuries sustained in violent contact sports, such as rugby – the players of these sports participate willingly, in the knowledge there’s a high likelihood of serious injury, which also causes unnecessary cost to healthcare services. It’s difficult to imagine a world where, prior to emergency treatments, friends and family are quizzed on exactly how the injury was sustained before the treatment is delivered. There are other examples – high blood pressure is associated with many cardiovascular diseases and often caused by high sodium levels in the diet.
While this is another example of patients knowingly impacting their own health at the expense of the NHS, a high-sodium diet cannot be obviously identified by looking at a person, and it would be impossible to determine the root cause of high blood pressure in each patient. Furthermore, depriving so many people of life-saving surgeries and treatments would have a severe effect on the UK’s economy, as many people would end up crippled with enormous debts to private healthcare services, which may severely affect their consumption of other goods and services. To further this point, a restriction on healthcare for the obese and smokers would primarily affect the working class. People from lower income backgrounds are around 6% more likely to be obese (“Obesity”, 2011) and more than twice as likely to smoke (P. Niblett, 2016) than higher earners. Therefore, saddling this group with obscene medical costs is likely to be counterproductive; families already struggling financially are unlikely to be able to pay back in full debts incurred due to obesity or smoking related surgery, meaning the UK government would incur the costs anyway. Increasing financial burden on the poor is an example of incredibly inefficient resource allocation, not to mention fuel for the growing problem of class divides. Alternatively, some people may be forced to make the decision to not receive lifesaving or –improving treatments for their illnesses, which will again be costly to the economy. If their health depreciates further, there will be fewer able-bodied workers and unemployment will rise. Furthermore, a large proportion of severe drug addicts are homeless. It’s incredibly unfeasible that these people would be able to pay back medical fees for treatments; instead, the death rate among the homeless would likely increase. This represents an enormous missed opportunity cost for potential workers to stimulate economic growth.
The above argument refers mainly to direct medical costs – for example, if a person were to walk into a private hospital and ask for a surgical treatment – which tend to be more expensive in the long-term than taking out private health insurance. However, the insurance option is also unlikely to be successful. In the UK, it’s both perfectly legal and commonplace for smokers and obese people to pay up to 50% more for the same coverage as a healthier person, a fact which would severely affect the ability of these groups, particularly in low income households, to obtain and pay off their monthly insurance. It may argued that, given the current shortcomings of the NHS, those who can feasibly afford private healthcare already use it – so even those who aren’t in the lowest quartile of income are likely to struggle to afford private insurance. So in cutting off free healthcare to so many, we’d undoubtedly be condemning some to inadequate healthcare and therefore – in the most extreme of cases – death.
Another argument arises if we view the problem from a purely economic perspective. Researchers have found that the actual overall cost to the NHS of obesity is much lower than is commonly quoted, simply because severely obese patients have a much shorter life span and therefore incur almost no age-related illness costs. More than two-fifths of the NHS’s budget is spent on over-65s (Nuffield Trust for the Guardian, 2016), costs which are often avoided by the early mortality of the severely obese or smokers. Furthermore, those who die before retirement save the state over £500 per month in pension costs. Studies attempting to weigh up the costs versus savings of obesity vary in the estimate overall ‘net’ costs. Estimates range from an overall net cost of around £2.4 billion (M. Tovey, 2017) – less than half of the £6 billion figure often cited as the cost of obesity to the NHS – to much lower.
A 2008 study by researchers in the Netherlands even argued that obesity saves healthcare services money overall (van Baal et al, 2008) – however, of course this study doesn’t take into account the opportunity costs of so much of the population dying before the age of 65. This effect was also evident in a 1997 study analysing the effect of smoking on long-term public health costs. One researcher estimated that “a 1 percent decline in cigarette sales increases costs for medical care by $405 million among persons 25 to 79 years old” (J. Barendregt et al, 1997). These arguments ignore the social and ethical side of obesity; a government’s aim is to provide reasonably long, high-quality lives for its citizens, which severely obese patients may not obtain. It also doesn’t take into account the lost years of productivity that early mortality causes. But the proposed savings of £6 billion a year with the eradication of obesity are as unrealistic as the £350 million per week for the NHS promised by the Leave campaign prior to the EU referendum.
To further this slightly uncomfortable argument, the so-called ‘junk food’ industry is enormous and contributes huge amounts of capital to the UK economy. If the ‘end game’ of restricting healthcare access to obese patients is to eradicate obesity in the UK, many food industries would take an enormous hit in revenue, leading to less money recycled back to the government in taxes. Of course, it could be argued that unhealthy food may be consumed as part of a balanced diet; or that the money saved on these foods would be spent on other, healthier foods, so the effect would be counteracted. However, this argument falls apart when applied to smoking. The cigarette industry brings in directly around £12 billion a year in tax revenue (“Does smoking cost...”, 2015), more than twice the very highest estimate for the expense of the NHS on smokers. So eradication of smoking would cause a net loss of £6 billion a year for the UK economy. It’s certainly true that the debate over whether or not healthcare should be privatised for those deemed undeserving is complex, with strong ethical, social and economic arguments both in favour and against.
There is no definitive answer as to whether or not a policy preventing the obese or smokers from accessing free healthcare would be successful in terms of improving public health or reducing NHS spending. The factors influencing estimates regarding the costs and benefits of such a policy are usually wildly speculative figures, simply because we don’t know how it would affect society. And it’s unlikely that we’ll ever find out; given that 63% of the UK population is currently considered overweight or obese (C. Baker, 2017), any government considering radical changes to access to free healthcare would be undoubtedly voted out before any such changes could be implemented. But from an ethical perspective, freedom and equality are hallmarks of a democratic country, and legislation to prevent access to public services due to lifestyle choices represents a disregard for both of these core values. Children who truant from school aren’t banned from public education; litterers aren’t forced to pay premiums to drive on public roads. When the NHS was launched in 1948, its three core principles were laid out as follows: “that it meet the needs of everyone”, “that it be free at the point of delivery” and “that it be based on clinical need, not ability to pay”. 69 years later, the current slogan on every page of the NHS website is “Your health, your choices”– an unambiguous statement.
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