One of the most common ideas in the whole healthcare financing discussion is a moral one. Why, people say, should my taxes and my healthcare premiums go to take care of the huge medical problems of people who don’t take care of themselves? As one commenter on put it: “…self inflicted injuries to not be covered at all, ideally. If someone drinks their liver away I don’t think we should all have to buy them a new one. Same for smoking.”

This is a common idea, one that seems logical and right on the surface. But there are four assumptions built into it, all four of which have problems:
1) That the “self-inflicted injuries” that people commonly identify (smoking, drinking, other addictions, obesity) actually are major predictors of cost.
2) That we can clearly differentiate “self-inflicted injuries” from other medical problems
3) That to the extent that they are actually “self-inflicted,” the patient could just stop doing them if they just had enough gumption, or enough something.
4) That if our goal is to cut unnecessary medical costs, refusing medical coverage would cut costs.

But each of these four is problematic.
1) The best predictors of medical costs are not smoking, drinking, or obesity, but depression and stress. (“Association Between Health Risks and Medical Expenditures,” So trying to dis-insure “self-inflicted injuries” might miss the target of lowering healthcare costs.

2) Trying to decide what is “self-inflicted” and what is not presents a major problem. A friend has a lifelong condition that gives him excruciating pain. He has struggled manfully (and successfully) against addiction to booze and painkillers to ameliorate his pain. He has always felt bitter toward his father because his father was addicted to booze and painkillers. He recently realized that his condition is genetic, and guessing from some symptoms he observed, realized that his father was fighting the same excruciating pain. His attitude toward his late father changed instantly.

You can easily see other people with addictions and troubles that you don’t have. What you can’t see is what led them to that situation. You may be the very model of the perfect human, with no addictions of any kind, nothing in your life that you don’t want there, and you have never made any mistakes in your life that could have led you down the wrong path. Maybe. But even if you are, who exactly would you want sitting in judgment about which of your medical difficulties are “self-inflicted,” and which are not? Your individual doctor? Or a committee, say? A “death panel?”

3) The idea that people with “self-inflicted” problems such as smoking, drinking too much, other addictions, or obesity could just stop doing them is blatantly, obviously, provably false. And if it is false, then we have no logical or moral basis for refusing to help people who have those problems. Even if they could have avoided those problems by making better choices in the past, it is very difficult to unmake those choices now. They need a lot of help.

4) If your goal is to spend less on these people, making sure they don’t get coverage won’t do it. People with coverage cost the system less than people without coverage. In fact, they cost the system half as much. ( No matter the source of their problems, self-inflicted or not, it costs less to give people with lots of problems more, smarter, earlier care rather than less — unless your plan is to just take them out and shoot them when they show up in the ER.

So no part of the idea that we can and should reduce healthcare costs by refusing coverage of people with “self-inflicted injuries” is supportable. In the end, it makes no sense.