Universal Healthcare—Again

Someone recently took me to task for my musing about a year back on whether imposing certain lifestyle standards might make universal healthcare more appealing to a larger number of people. The substance of the opposition to my post was that food/drug/alcohol addiction were diseases and it was not reasonable to just expect people to straighten up and fly right if they wanted the rest of us to foot their healthcare bills. First, let me say that, personally, economic reasons alone are enough justification for me to support a single payer NHS, as in Canada. But I represent the minority in this matter. As to the contention that these various excesses are diseases, that bears a bit more scrutiny.

Lets consider drugs. Very few people in the US are addicted to illegal drugs (cocaine, meth, heroin); probably less than 3% of the population. The major cost of drug addiction is incurred by virtue of its illegality. If current cots associated with prosecution and imprisonment were diverted to treatment, much of that problem would largely be solved. I am all for that. As for alcohol, the vast majority of users who experience adverse health effects from drinking are not considered alcoholics in that they continue to function in a socially acceptable way, maintaining commitments to family, job, etc. Yet, they still become a burden on the healthcare system at this level. Since they are not addicts, the factors influencing their drinking are not that complex and they could stop and cut down if they so chose. As for true alcoholics, treating them with government funds just makes economic sense. Any expense would be more than offset by gains in worker productivity and reduction in accidents.

Now, being overweight. 2/3 of Americans are overweight, while 1/3 are obese. It is well-established that the primary cause of being overweight is simply overeating. Do people who cannot control their weight have a disease. I would say no. Again, there are a certain % of compulsive eaters who probably cannot control themselves. But, the drive to overeat is actually hard-wired into all of us humans. It is now considered likely by most geneticists and evolutionary biologists that the drive to consume food in excess and convert it into fat during times of plenty is an adaptive trait. Those who could store fat in this way survived periods of famine and passed on their genes to the next generation.

So much like other biological urges, such as sex and waste excretion, restraining one's impulses in the consumption of food is actually the mark of civilized versus animal existence. We don't copulate or defecate whenever the urge moves us as it is socially unacceptable to do so. However, the same social stigma does not exist for overeating. In fact, it is culturally ingrained in citizens of rich countries throughout history that a little extra meat on the bones denotes success. While there is certainly pressure to be skinny in our culture, I think this phenomenon is grossly overstated when most people seem content with their fat selves and fat partners.

It is also true that the world's fattest people are found in America, England, Australia, and New Zealand. Why do we seem to suffer from this alleged disease at far higher rates than our counterparts in other countries. Why are the French, Italians, Japanese, and Chinese generally much slimmer than we are? They have the same biological imperative, yet they seem to have more discipline in their eating. Perhaps there is something about life in these anglo societies that is so unfulfilling or angst producing that many of us cannot control our urges. But I would call this a stress-coping mechanism rather than a disease, per se. Admittedly, this coping may not be easily rectified in a land where people are overworked, underpaid, scared all the time, and provided with no safety net by their government. Yet, America alone fits that description. It is not true of the rest of the chubby anglosphere. No, it appears we have chosen to indulge ourselves in our largesse and thus we are the largest.

Finally, smoking. This takes the greatest toll on our health and places the greatest burden on our healthcare system as a result. Nicotine is highly addictive and there are a very large number of addicts. Or are there. In parts of the country where there are laws and social stigmas against smoking, the rates are much lower. So Californians seem to suffer from less of this so-called disease than Georgians do, for example. The same is actually true of being overweight (at least when comparing similar populations, i.e., white, middle-class Californians are far less likely to be overweight than their southern peers). Now, who are the most likely to be fat or smokers? The answer is the poor. So again, we see something more akin to a stress coping mechanism than disease.

So, while I reject the idea that most people with bad habits cannot break or minimize them, I also believe that life in the excessively free market US is probably the main reason our citizens need to cope with food, drugs, and alcohol at levels far greater than those in mainland western Europe and Japan (though, granted, tobacco smoking is quite high in these other parts of the world, the generally more healthy lifestyles of their resident, with regard to diet and exercise, seems to afford them some protection against this vice as evidenced by their mortality and morbidity statistics). So, perhaps ironically, in the midst of an argument for setting a lifestyle test for universal healthcare, the case is also built for creating the social safety net and worker protections necessary to provide enough ease of mind to take control of these other variables. And this social safety net would have to include healthcare, as the stress of being without it is just one more factor that contributes to bad lifestyle in the first place.

As with my last post on this subject, which largely rebutted my first post, this one seems to add further weight against that initial diatribe. So if we offer universal healthcare to all and make a fitness test part of the package, we must also make other changes to way most people live in America in order to make the first part of the equation doable for most. But I do stand firm in my belief that if we just offer people a cushion with no incentive to change, then most will just go on doing what they have always done. If it is true that given the right social factors, most (though not all) Americans could overcome or minimize most of their health damaging habits, that would be a great gift to all of us.