One year ago in these pages, Harvard Medical School’s Stephen Soumerai wrote a scathing essay arguing that employer fines on overweight employees were ineffective. We’re here to tell you that Professor Soumerai is a cockeyed optimist. A new review in the American Journal of Managed Care shows that these fines transcend ineffectiveness. They are counterproductive.
To begin with, forced corporate weight loss programs don’t work. Of roughly 1000 wellness vendors promising weight loss, only one, the iDiet, has received validation. Literally no other corporate weight loss program can check three simple boxes that are standard in medical research:
- The study was controlled the way grownups would define “controlled,” not using unmotivated non-participants as a control for motivated participants, which Health Fitness Corporation inadvertently invalidated
- the program was sustained for 18 months, rather than eight weeks, which seems to be the new standard for get-thin-quick programs; and
- The results showed both high persistence and significant weight loss.
Even that study had significant limitations: One could argue that the sample was small and even 18 months was not a long enough period to determine if weight maintenance was likely to be permanent.
As compared to the 1-in-1000 vendors with legitimate study designs and results, we’ve outed thirty programs, like ShapeUp’s, that simply make up weight-loss outcomes. Usually (as in ShapeUp’s case), data manipulation takes the form of reporting “last man standing” outcomes ignoring dropouts and non-participants, which in ShapeUp’s case comprised the vast majority of all eligible employees. Shape-Up went a step farther, and failed to report on people who had gained weight over the period. (Their report, on their “success” at Highmark, has disappeared from their website.)
Let us assume, for a minute, that these programs could help people lose weight and sustain the weight loss. What would the impact be of that weight loss on healthcare costs and productivity? Looking at healthcare costs two totally different ways yields the same results. Government data attributes 3% of healthcare spending to increased obesity. A company that succeeds in reducing that by 10% would save 0.3% of all health spending.
As an alternative methodology, use wellness-sensitive medical events. They account for about 4% of spending. Reducing that by 10% would save 0.4% of all healthcare spending. Even if these numbers are off by a factor of 10, the net impact would still be a trivial reduction in total corporate expenses.
Nor is there any savings in productivity. Fatter people don’t type, talk, present, drive, teach, write, add, cross-examine, subtract, paint, prescribe, assemble, or do anything else (except maybe deliver packages or steal bases) more slowly than thin people—which is why fatter states and countries enjoy economic growth equal to or greater than their thinner counterparts.
Once again, even if we’re wrong and there is a trivial positive impact on productivity, it couldn’t approach the program expense and especially the morale impact of shaming, demoralizing and invading the privacy of employees. Employees hate these programs, which is why fines are needed to force participation. Even so, occasionally they revolt (like Penn State and CVS) or sue (Honeywell).
So far, our conclusions agree with Professor Soumerai’s. But as mentioned above, we go a step farther and put these programs in the realm of “counterproductive,” not just ineffective.
Attaching money to weight loss would naturally lead to bingeing before the first weigh-in, followed by crash-dieting before the last one. Perhaps even more importantly, a growing body of literature supports that repeatedly losing and gaining weight is not benign. (see footnote below) In fact, it may actually worsen many of the conditions that losing weight is supposed to cure. Even companies that make their money off weight cycling don’t endorse it.
Beyond that, some programs, notably Aetna’s, can specifically harm employees in the name of wellness. Aetna has partnered with a couple of unsuccessful drug companies to pitch obesity drugs to obese employees, drugs whose hazards prompted an editorial in JAMA Internal Medicine arguing that they never should have been approved. (One of these drugs is Belviq, which has the 3rd highest ratio of physician payments to sales of any drug.) Aetna has failed to disclose this editorial, and declined to answer questions about their program, including how can they position these drugs as “increasing productivity” when the drug’s disclosed side effects include impaired memory, attention, and language.
A great question is, why? Why would employers undertake programs that demonstrably fail, damage morale, and even sometimes harm employees? While stupidity and dishonesty can never be ruled out in situations in which benefits consultants are the major source of advice, there appears to be another more insidious motive: these fines themselves are now major sources of savings, as Bravo Wellness says on its website.
There is some good news. Companies that don’t obsess with their employees’ weights enjoy a significant competitive advantage in recruitment and retention simply by spending time maximizing the value of their endeavors rather than humiliating employees with weight concerns. So speaking as three people who all run small enterprises, we encourage our competitors to interfere as much as possible with their employees’ personal lives. Since it’s bad for their businesses, it’s really good for ours.
Ref – D.M. Bhammer and G.A. Gaesser. “Health Risks Associated with Weight Cycling.” In Wellness, Not Weight: Health at Eery Size and Motivational Interviewing. Ed. Ellen R. Glovsky. San Diego: Cognella, 2014.
Al Lewis and Vik Khanna are co-authors of Surviving Workplace Wellness with Your Dignity, Finances, and Major Organs Intact. Their website, They Said What, regales readers with stories of wellness innumeracy and deception.
Dr. Jon Robison is co-founder of Salveo Partners and co-author of the newly released, How To Build A Thriving Culture at Work: Featuring The 7 Points of Transformation.
Awesome blog posted. Appreciate for sharing it.
Blood Glucose Monitoring
NEGATIVE CLANK by Richard Brautigan
He’d sell a rat’s asshole to a blind man for a wedding ring.
Get it fellows?
Before you luxuriate in too much schadenfreude regarding the state of our businesses, you might want to check to make sure your internet connection is working.
I’m just sayin’…
Some of the firms doing “smart” health programs now, did “dumb” health care programs once.
Our “professional” attention-mongers, Al & Vik, figure the thing to do is shriek at anyone doing what they find is the “horribly wrong” thing, regardless what stage the maturation of those miscreants’ health strategies.
Great strategy, guys – shrill condemnation is sure to win you boatloads of converts. Of course, if that was working out for you, we’d hear much less FROM you, since you’d be so busy helping out all those clients of yours…..
” Government data attributes 3% of healthcare spending to increased obesity.”
I read the CBO link– and their derivation of the “3%” has more nuance than the context in which you cite the figure. Overall costs of obesity significant. The CBO looks at population based (not worker) costs, shifting trends in wts, and spending over a life cycle.
Obesity in and of itself is not unhealthy-it is just excess adipose tissue, stored energy. The more insidious problem is the underlying metabolic condition that drives it, which also drives stroke, heart disease, arthritis and on and on-diseases of inflamation. This is THE issue for the sick care system. If you read the dietary advice is nearly every wellness vendor you’ll find it is based on the standard, wrong government advice that got us to this place. I knew twenty years ago (through my own research and a wonderful physician) that cholesterol was a bogeyman and fat was not only not bad for you, it is healthly if not from a CAFO animal. There is a reason hunter-gatherers eat the organs first, then the fat, and give the muscle to the dogs.
I could go on but you get the idea.
You need to tell the CBO.
Don’t we have to extrapolate a bit to find some principles here? Firms that are too OC are like military units and have a bunch of problems recruiting, one of which is that many personality types will not apply. Dancing troops like Cirque or special forces subcontractors might need this type of discipline and the fines that go with this need. These are few.
Yet most firms would surely have a desire to want to minimize–despite the labor laws–persons who are too hairy or too tall or too short or too fat or too smelly or too slow or dumb, ugly, psychopathic, silly, et al.
But, you could also have firms that need to minimize all constraints on their workers, largely because these people are so rare and valuable. Hence, hands off on software wizards or advanced mathematicians or physicists. Let them be as unkempt and fat or smelly as they want.
Also, it seems uncertain if high risk behaviors are more costly to society in general. We may pour more welfare money into these folks for awhile, but they may not survive as long. Eg smokers, rock-climbers, commercial fisherman. Maybe we all even out in the long run? But in firms, the obese probably do cost more. But is it worth the C/B to fine them?
Then we have the direct and opportunity costs of rules and more rules. ychhh!
I support the authors.
Kudos to Lewis, Khanna and Robison for pounding on this weighty health & wellness topic.
I think weight loss fines could be very productive if they are levied correctly:
Fine all employers who go over a 40 hour work week (thus prohibiting me from going home and being active). Fine employers for not providing a clean and functioning personal food preparation area to embrace healthy eating with fresh food. Fine employers who don’t allow at least 4 weeks of vacation to account for gardening, exercise and appropriate decompression. How is that for an employee wellness program? I will grow 6-pack abs if this program is ever deployed. Otherwise, employers need to stay out of my biz and worry about their own bloated butter martini drinking executives.
You should run a company!
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No doubt these fines are discriminatory – can anybody clarify the legal framework that employers use to justify them?
Do we have a prior court decision?
My sense is that there have been few suits filed in these cases because of the perceived intent – many of these companies believe (rightly or wrongly) that they are helping their employees ..
I’d recommend reading both the original link to Professor Sumeria and then this one–and watch the wellness industry go from bad to worse right before our eyes in a year. My company has a program and we all game it to collect our “incentive” and laugh at the idiots in human resources who come up with these things.
Thou shalt not covet thy neighbour’s cholesterol.
One way to stifle a free society is to be intolerant of people’s poor choices.
Even libertarianism can go too far.
“Even libertarianism can go too far.”
I don’t understand…please elaborate. Thanks
To be so obsessed that people pay for their bad choices, so that the bungee jumper pays for the detached retina, the hiker in Yellowstone pays for being mauled by a grizzly bear, requires a contractual order so enormous, and a legal machinery so leviathanic, that it actually stifles freedom by over lawyering society.
An uptight society, an uppity society, is not a free one.
Freedom needs people to take a chill pill.
You might find France, in some respects, freer than USA.
Are you suggesting that Paul pay for the bungee jumper’s detached retina?
If Paul frets too much about diffusion of costs he will need his personal lawyer.
You must be referring to something said on a different thread because I don’t see Paul fretting on this one. However I am still confused. The bungee jumper wishes to enjoy himself and in doing so risks a detached retina. You suggest that Paul, at least in part, be obligated to pay for that detached retina even though Paul did not get to share in the dubious pleasure of bungee jumping. Then you suggest that if he is not held responsible for the costs of the bungee jumper he will need a personal lawyer. This is one of those rare occasions where I cannot follow your logic.
Of course you won’t follow my logic allan, if you think linearly. When you think linearly (x is good, so 10 x is 10 times better, 100 x is 100 times better, 1000 x is thousand times better) you might fail to appreciate that any political principle, even libertarianism taken to an extreme, curtails freedom.
How far will you take the notion that people should pay for their choices? That you should not be financially punished for their bad genes? How will you enforce it?
Taken to its logical conclusion, it means reams and reams of contracts, scores of lawyers and ton of angst fretting whose microcosts are macro-diffused.
It makes for an uptight, overlawyered and less free society.
To appreciate this allan you’ll have to be comfortable that these two notions are not contradictory.
a) Extreme libertarianism curtails freedom.
b) Moderate libertarianism enhances freedom.
You are accusing one of thinking linearly and then put everything into one big box. That doesn’t seem logical. No one is talking about any extreme nor has anyone defined what that extreme is. We are simply asking why you are suggesting that Paul pay for the bungee jumper’s detached retina. You need to provide a substantive answer, not a quick retort where you try to turn the tables by accusing others of thinking linearly while avoiding an answer to the question.
You are creating straw men. It is not a matter of blaming another for his genes, but if someone has a gene that commands them to kill one person a day I don’t let them run free either. But, what does all this have to do with the underlying question of Paul paying Peter?
You are trying to draw a logical conclusion with rhetoric absent of substance.
Where have I ever promoted extreme libertarianism? I just don’t feel that Paul should be forced to pay for the bungee jumper’s detached retina that occurred because the bungee jumper voluntarily accepted risks and now has to be responsible for payment of that detached retina.
“We are simply asking why you are suggesting that Paul pay for the bungee jumper’s detached retina.”
See Paul’s question to my first post.
I’m glad you agree that extreme libertarianism is tyranny, which was my point, that extreme libertarianism is tyranny.
The detached retina is an example. One needs examples to illuminate points. If you focus on the example you will miss the point.
But the example stands well. A society which insists that the bungee jumper pays the cost for his detached retina (Paul alone won’t bear the cost), is one which objects to those micro costs being diffused. In such a society the contracts and legal machinery will be enormous.
That is a society that is uptight about individualizing choices and costs is a less free one.
Are you able to argue the merits and demerits of the last sentence without vicariously accepting agency for Paul?
If it helps you can substitute Paul with Peter. The question and proposition remain the same.
“See Paul’s question to my first post.”
Which post is that? Paul’s comment was as follows: ““Even libertarianism can go too far.” I don’t understand…please elaborate. Thanks”
“I’m glad you agree that extreme libertarianism is tyranny,”
Tyranny suggests government. Extreme libertarianism would suggest anarchy, right?
“The detached retina is an example. One needs examples to illuminate points. If you focus on the example you will miss the point.”
You should use a better example. I can envision many points so I have the choice of which point I wish to use. The points I think you might wish to make are not well served by your example.
“But the example stands well. A society which insists that the bungee jumper pays the cost for his detached retina (Paul alone won’t bear the cost), is one which objects to those micro costs being diffused. In such a society the contracts and legal machinery will be enormous.”
The statement represents a logical fallacy and your conclusion relies upon a cause and effect relationship that is not proven. [Just because one doesn’t feel it his obligation to pay for another’s foolishness doesn’t mean that same person would object to costs being diffused. Just because a society refuses a mandatory obligation towards Peter’s pleasures doesn’t mean the micro costs aren’t being diffused. (see below)]
Paul is not insisting the bungee jumper do anything. He is simply exerting his natural right not to be obligated for the foolishness of Peter the bungee jumper. Peter, the bungee jumper, has many alternatives. He doesn’t have to bungee jump. He can make sure he is able to pay for his retina surgery. He can buy insurance. He can ask for charity. If it is a commercial adventure selling the bungee jumping experience Peter can make sure they are insured. Why all of a sudden are you obligating Paul to be responsible for Peter’s pleasures?
Chill out 🙂 a free society permits one to take advantage of a cold beer while another can have his Scotch. Each can pay for his own and choose his own hangover.
“Which post is that? Paul’s comment was as follows: ““Even libertarianism can go too far.” I don’t understand…please elaborate. Thanks”
Good. We are at least on the same page!
“You should use a better example.”
It’s a perfect example because it isolates the wilful foolishness of the act and its consequences (deceleration – retinal detachment).
If the person is not held for the act the costs will diffuse to society – which includes Paul. If the person is held then that holding will cost – i.e. it will cost to make sure the bungee jumper pays for the consequences.
If Paul does not want to pay, even in concert with others, for the consequences of someone else’s choices, and there several he won’t know about, there must be an enforceable mechanism to isolate those choices and consequences.
That is synchrony of choice and costs, leads to transaction costs. One of the costs is an over lawyered society, which is paradoxically or perhaps not, less free.
It seems to me that you are unable to miss my point, yet unwilling to acknowledge it! That’s ok, with me.
“It makes for an uptight, overlawyered and less free society.”
I think we’re already there, Sauabh.
I don’t think I will sleep well tonight….worried about all those radical libertarians!
I get a whole bunch of points you are making, but don’t find much merit in them compared to the other points you may or may not have considered.
Paul asked you to explain and even in this response you didn’t say why you referred me back to Paul’s statement. Your referring me back to Paul’s comment was immaterial to our ongoing discussion. It didn’t answer the the reason Paul should pay for Peter’s follies or why we would be overburdened with attorneys if Paul wasn’t compelled to pay. Even your statement that too much libertarianism resulted in tyranny confused the issue when too much libertarianism leads to anarchy.
“It’s a perfect example because it isolates the wilful foolishness of the act and its consequences (deceleration – retinal detachment).”
You are being very judgmental. Though I might find bungee jumping a foolish act for me who am I to judge what is foolish for another person? …And what does that have to do with our discussion where you wish to force Paul to pay for what you consider to be Peter’s foolish act? In this latest response you do confuse the issue when you talk about the jumper paying for the consequences In my way of thinking the bungee jumper should, but then you try to defend your central argument (which is indefensible) by telling us that Paul’s choice has to be defended by the legal system (when it doesn’t) concluding that Paul’s refusal to pay leads to transactional costs when it doesn’t. Peter can pay, can have insurance or might have to live with the detached retina. There is no need for attorneys until you create an obligation for Paul. [ I know I am being cruel not forcing Paul to pay for Peter’s foolishness but Paul wants to buy new tires on his car to prevent his kids from dying in an auto accident. I’ll opt to help Paul’s rational desires rather than support your … no … Peter’s foolishness. Someone has to protect Paul from the craziness I am hearing.]
“One of the costs is an over lawyered society, which is paradoxically or perhaps not, less free.”
Incentivizing Peter to carry insurance for his foolishness doesn’t increase costs. It decreases them and as a by product all the Peter’s of the world might become more responsible.
I am neither missing your point nor not acknowledging it. If you disagree you either are not clear or your point simply doesn’t have the merit you think it has.
Adults teach responsibility to children. One of the ways of teaching such responsibility is to let the children face the consequences of their actions. Do you have children?
Summary of appropriate responsibility: Paul is not telling Peter what he can or cannot do. Peter is not obligating Paul to pay for his pleasures. The method you are supplying is filled with logical fallacies.
” Your referring me back to Paul’s comment was immaterial to our ongoing discussion”
allan, it seems difficult for you to break a circuitry loop! God knows what would happen if you stared in to parallel mirrors.
So let me keep this simple, as anything mildly metaphorical seems too esoteric for you.
How will you ensure people pay for the consequences of their choices?
Once you answer this, I will ask the next question.
I am determined to walk you through this one, allan! And I shall not be deterred by your repeatedly pretending to miss the point.
Paul, do you mean Halbig?
“It seems to me that you are unable to miss my point, yet unwilling to acknowledge it!”
I find your point to be near meritless and somewhat hidden behind good prose, but that is from my vantage point which is one that doesn’t believe you should whimsically be imposing obligations upon another.
I’ve been more than clear in my position. I will not obligate Paul to pay for Peters pleasures. That you wish to do so is your problem and has nothing to do with a circuitry loop or parallel mirrors. Do you think we are at a carnival where such tactics are accepted?
I will answer your question though it has actually been answered in almost every reply.
The question: “How will you ensure people pay for the consequences of their choices?”
The answer: Paul will not be forced to pay for Peter. Peter will have to face the consequences of his poor decision and if necessary live with a detached retina. That will incentivize the rest of the Peters to carry insurance, not display what I consider to be foolishness or to find a way to pay for their own choices.
Now you can go on to your next question, but how do you deter foolish expenses by Peter if you force Paul to pay for them?
Darn, I was hoping to wake up this morning to the next episode in the allan/Saurabh dialogue which explains how (playing the role of libertarian) refuses to pay for Peter’s bungee cord injury….and how that leads to a dystopian future run by lawyers……think of a new Mad Max episode in which all the guys riding around in pick up trucks with machine guns mounted are dressed in Brooks Brothers suits….and they have converted the machine guns to spit out supeonas, summons and court orders.
I have already written a script synopsis and sent it to my lawyer….he assures me we can defend our rights if any of the THCB readers try and rip off my idea. Alas, my attorney was wearing a JC Penny suit….but I assured him he soon would only be wearing Brooks Brothers!
“I will answer your question though it has actually been answered in almost every reply.”
But you have not answered my question: “how”. You have answered “why” you will make Peter pay for his choices. You’ve told me that you won’t make Paul pay for Peter’s choice.
You’ve told me the positive effects of making Peter pay for his choices.
But you have not answered how.
How will you make Peter pay for the detached retina from his bungee jumping?
(the answer is simple, but I want you to arrive at it yourself)
Of course I answered your question. You just don’t like the answer. I’m going to copy a previous answer and then explain it followed by a different script to make my point even blunter.
“The answer: Paul will not be forced to pay for Peter the bungee jumper. Peter the bungee jumper will have to face the consequences of his poor decision and if necessary live with a detached retina. That will incentivize the rest of the Peters to carry insurance, not display what I consider to be foolishness or to find a way to pay for their own choices.”
Answer to how: Paul will not pay. If Paul doesn’t pay Peter the bungee jumper will live with a detached retina or find another way to have the retina repaired.
“(the answer is simple, but I want you to arrive at it yourself)”
New script to help you “to arrive…”.
Peter, the bungee jumper rapes a 14 year old girl. Before trial he is given bail for $500,000. Unfortunately for Peter the bungee jumper, he doesn’t have enough money to pay for the bail bond and that is making him very upset because he wishes to go bungee jumping again. Paul recognizing Peter the bungee jumper’s plight and remembering that Peter can no longer see from one eye decides to loan Peter enough money to cover the bail bond. Peter the bungee jumper gets out of jail and goes bungee jumping, but that is another story.
Peter the bungee jumper wins his case and is not jailed for the rape he committed because the jury felt sorry for him especially with his blind eye and the young girl was too horrified to testify. Peter the bungee jumper no longer bungee jumps but likes fast sports cars and is now racking up speeding tickets. He has given up on raping young girls.
Paul asks for his money back, but Peter, no longer a bungee jumper, refuses. He needs the money to pay for the loan on his new Porsche and tells Paul he doesn’t have the money. Paul takes Peter to court.
The judge responds:
A) Too bad Paul you shouldn’t have loaned him the money. or
B) Paul wins the case. Paul didn’t rape that 14 year old girl so why should he pay for Peter’s bail? The penalty was against Peter not Paul.
Saurabh, you can chose either A or B. There may be a C and even a D, but of the two choices A or B which is the better choice?
“Of course I answered your question.”
No you haven’t. You have digressed in to a ramble.
How will you make sure that Peter pays for the detached retina from bungee jumping? Let’s stick to this case.
I will give you one more chance and then tease you with a possible answer.
“I will give you one more chance and then tease you with a possible answer.”
You are asking how *I* would make sure that Peter pays for the detached retina. Saurabh, that means you are looking for my answer, not your own, so you can’t tease me with a possible answer because the chances are that I know that answer, but I do not believe in creating new obligations for others especially since they have obligations of their own.
I wrote “Of course I answered your question.” to which you curtly responded “No you haven’t. You have digressed in to a ramble”. The only ramble I have seen is your rhetoric absent substance though with a few big words and good prose. You are a good writer, but sometimes content is more important and reading what another says is doubly important.
Are you going to tell me the prior response (following in quotes) doesn’t answer the question you posed??? [“But you have not answered how.”]
“Answer to how: Paul will not pay. If Paul doesn’t pay Peter the bungee jumper will live with a detached retina or find another way to have the retina repaired.”
I’ll expand the answer to “how” so you can see how these things work. Maybe Peter the bungee jumper wasn’t as stupid and didn’t require so much paternalism directed his way. He might be carrying insurance or he might have earned enough money that it was available to pay for his detached retina. Peter could have had a Porche or home so I wonder how Peter paid for the Porche. Hmmm. Can anyone think of a way? Yes, he can do what most Americans do and take out a loan or place a second mortgage on his house.
“How will you make sure that Peter pays for the detached retina from bungee jumping?”
Read the words above again. What makes you think it is anyone’s obligation to pay for Peter’s stupidity? We could of course ban bungee jumping and any activity that causes harm. Bye bye ski vacations. That type of action is what some very paternalistic folk advocate. That would save more attorney costs than anything else you suggested. Personal injury attorneys who generally side with paternalistic leftists would fight against that however, not because they like to ski, but they sometimes they depend upon the stupidity of the Peter’s of the world hoping the deep pocket Paul’s will make them rich.
Now you can reciprocate by answering my question:
“A) Too bad Paul you shouldn’t have loaned him the money. or
B) Paul wins his case. Paul didn’t rape that 14 year old girl so why should he pay for Peter’s bail? The penalty was against Peter not Paul.
Saurabh, you can chose either A or B. There may be a C and even a D, but of the two choices A or B which is the better choice?”
“What makes you think it is anyone’s obligation to pay for Peter’s stupidity?”
This is amazing. I no longer believe that you are deliberately obfuscating – my apologies for doubting you. You really don’t get the issue. There is an impasse here. You really don’t understand the question.
That no one but Peter should pay for Peter’s stupidity is a moral issue. The question I’m asking is not whether this moral issue is right or wrong. What I am asking is how will society enforce that Peter pays for his stupidity and that those costs don’t diffuse to anyone else?
There is an answer here. A simple answer. It’s called contract. Not social contract. No one need follow a social contract if they don’t want to. But an enforceable written contract.
Can we agree on the need for an enforceable contract? This has nothing to do with whether Paul should or should not pay for Peter. This has to do with how one ensures Peter pays for his detached retina from bungee jumping.
What you have been doing is giving me whole lot of arguments why it is morally wrong and unfair for Paul to pay for the health consequences of Peter’s indulgences.
What I have been repeatedly asking you is how would you isolate Peter’s costs to Peter.
Can we agree on contract so that we can move to the next part of the argument?
“Can we agree on contract so that we can move to the next part of the argument?”
No. Other than a contract between a willing buyer and willing seller the answer is no. My arguments are both philosophical and economic. You are trying to impart your ideology into the discussion and I won’t let you. That has frustrated you enough that you have become a bit condescending which is fine, but also a little insulting which is not. Your question to the present has been limited to “How will you make sure that Peter pays for the detached retina from bungee jumping?”
No one but Peter need pay for that detached retina at all. Since your question doesn’t include moral issues society need not even think about it.
I don’t have to play your games and jump through your hoops to answer an unasked question that only muddies the water even though I know from experience where you are coming from. I try and keep things clean and above board. If you have the bad taste to play these games do it with your Interns, not with me. …And by the way you haven’t answered my question which I feel is just as relevant to this issue.
“What I have been repeatedly asking you is how would you isolate Peter’s costs to Peter.”
That has been repeatedly asked and answered though this new question is phrased an a way that broadens the issue beyond the simple repair of a detached retina.
I suspect Saurabh must be thinking that Peter’s detached revenue limits his ability to contribute to society and that it is intolerable if it doesn’t get fixed….and that if we don’t compel Paul to pay for Peter then we must compel Peter to pay for himself…..I guess through a forced contract with legal penalties if Peter ignores his obligations.
Is that the point Saurabh?
I’ve been following this, but I don’t think the Socratic method plays well in a blog/comments section….respectfully, I suggest it would be best just to lay out one’s line of thinking.
“You are trying to impart your ideology into the discussion and I won’t let you.”
How utterly absurd!
How is my asking you a question imposing an ideology? And what ideology might that be Allan McCarthy?!
Of course, it’s about contracts. If healthcare is going to be covered by insurance, and not our of pocket, and you don’t want costs to diffuse, i.e. you want to isolate the costs that are consequent to Peter’s choices to Peter, you’ll need a contract.
I gave you an easy example.
How about the teenager who dislocates his ankle while running fast downhill. How would you prevent Paul(s), who don’t run fast downhill, from internalizing the costs?
You may take the fifth, but the rain won’t stop if you refuse to answer what you’ll do if it rains.
Paul you hit the nail on the head. I think we all know where Saurabh’s contract leads even if there is a variation to what you have stated. It is not the Socratic method that I find lacking in Saurabh’s commentary, but the fact that he truly believes his questions can lead to a singular answer, his answer when in fact there were many good pathways that could have been followed. His method would have been acceptable if it was only part of a pursuit, but his frustration got the better of him and he closed his usually open mind.
Now I am ready to deal with Saurabh’s contract.
Saurahb, suddenly you are adding a bunch of qualifiers not present in your prior questioning and you continue to stretch your boundaries. I have already provided you with my boundaries. I have not stated that any or all of the costs must be retained by Peter, rather I have provided my boundary which is I will not obligate Paul to pay for Peter’s foolishness. That the possibility Paul might pay for Peter’s foolishness exists. Think. What would happen if Peter, the speeder, caused an accident injuring Paul. Paul would be paying for Peter’s speeding habits that caused the two of them to collide.
Get on with it Saurabh and provide us with the contract you wish agreement upon “so that we can move to the next part of the argument”
I did not realize you were taking Peter’s problem as one in the current system….thought we were exploring core principles.
Since we are in a curent situation that includes forced free tx, you are right. But there are some simple reforms that would minimize Peter’s temptation to socialize the costs of his behavior. These include Dr. Ben Carson’s proposal for everyone to have a Health Savings Account (for the poor, it would be contributed by taxpayers)…..which means people are more careful in their behavior and in their consumption of medical services…..this is because the funds in the HSA are their own.
You are right this does not eliminate the exportation of Peter’s costs….but it creates an incentive for the Peter’s of this world to not do it.
I remain interested in your thoughts re the role of lawyers and contracts.
Paul, we most certainly were exploring core principles, but Saurabh has this tendency to alter the direction of the discussion and even the questions involved. I too remain interested in his thoughts re the role of lawyers and contracts since much of what I believe in involves well designed contracts that exclude excessive lawyering. So far it is like pulling teeth.
It is preferable to explore core principles before adding the complexities of our present laws.
“Is that the point Saurabh?”
Paul, I’m simply asking allan how he will isolate Peter’s costs to Peter.
He said Paul should not have to pay for Peter’s choices.
It begs the question how Peter will pay for the consequences of his choices.
This is not an argument over whether Paul(s) should pick up the tab for Peter.
I want to know how society will isolate healthcare costs to the individual that result from their choices.
The question is simple. The answer is, admittedly, tough,
“but the fact that he truly believes his questions can lead to a singular answer”
allan, I’m happy for you to give me a range of answers, just so that it doesn’t include this one:
Peter should pay for the costs because that’s the right thing to do,
Tell me, how will the market sort this one out. I’m all (frustrated) ears!
Very easily, openly and with very few words I explained my boundaries. Then I encouraged you to do the same and fulfill that which you had promised. Get on with it Saurabh and provide us with the contract you wish agreement upon “so that we can move to the next part of the argument”
Instead of doing so you played more games. You asked me to engage in a foolish guessing game and warned me not to include the following argument that adds nothing to the discussion.
“ Peter should pay for the costs because that’s the right thing to do,” Zzzz
Things seem not to be going all that well on your side of the railroad tracks. You were waiting to blow us out of the water with your argument that appears to include an “enforceable contract” and instead you find it a dud. That is what happens when you wait too long.
State your case and stop with the games. Your game is over. Now tell us what it is you wanted to say in the first place.
“State your case”
How will you ensure that Peter’s costs are not diffused to Paul?
(…..for the hundredth time, in plain English)
Let me try an experiment.
Allan, what are the colours of traffic lights?
(now if you understand this question you should be able to understand the first one. If not, I think you are deliberately obfuscating Comrade McCarthy!)
Here is another one for you to ponder about.
Peter eats fatty food, doesn’t exercise and has a family history of heart disease.
Paul eats broccoli and runs.
Peter has chronic heart failure, ICD and needs multiple medication.
Paul does not strain the healthcare with costs.
How will you make sure that Peter’s costs are not diffused to Paul? How will you make sure Peter is financially punished for his choices? Will you make allowance for Peter’s bad genes? How about the fact that he knew about his bad genes and still didn’t exercise?
What would be the mechanism to toll Peter fairly in your libertarian (pie in the sky) paradise?
“ it’s about contracts.”
Time to get on with it and quit stalling. I’ve answered your questions over and over. It is time for you to blow us out of the water. Tell us the answers. Are you afraid?
Comrade McCarthy? I assume you are talking about Senator McCarthy. You might not like him, you might not agree with everything he did, but the one thing that was true and proven about McCarthy was that he was right.
“What would be the mechanism to toll Peter fairly in your libertarian (pie in the sky) paradise?”
What makes you think I am libertarian? Don’t bother answering the question because at one time you asked if I was an Objectivist. I don’t think you recognize that people don’t fit into the slots you allocate for them. Suffice it to say that libertarians have a broad spectrum of political philosophies. Thus before classifying one as a libertarian a definition of terms is in order.
Now you can get back to the job of telling us about your “enforceable contract” so we can stop the games and get on with the discussion.
“Tell us the answers. Are you afraid?”
Yes, I am afraid. I am afraid that extreme fairness in healthcare, which takes many forms such as you and your costs should be separate from me and my costs, is practically unenforceable, and if one tries to enforce it, it will be a nightmare of contracts.
You asked how. It was pretty clearly spelled out. Nevertheless.
I walked you slowly through it, holding your finger – metaphorically that is, before you get yourself in to a righteous spasm of literal logic.
And here you stand, essentially agreeing with me, still struggling with the basic question – how will you isolate Peter’s costs to Peter? So badly have you struggled with the question that far from answering it you pretend that the question itself is invalid.
I couldn’t give a flying rat’s tail about your ideology – all extreme ideologies converge in a heap of contradiction, and are indistinguishable. You seem paranoid about socialists, which in the context of healthcare is ironic, and mildly amusing.
But you do have the advantage of being oblivious to irony, and I must say that I envy that bliss.
So go back to the drawing board and think again. It will come up again. How will you isolate Peter’s costs to Peter?
Psst, it’s called a contract.
The all knowing one has once again repeated himself, CONTRACT “It’s called a contract” but then runs and hides. No substance to anything said in your dozen or so replies. This is a superiority complex that has gone amuck.
In human interaction there is no such thing as total isolation from costs or anything else. That is something even a simpleton might understand, but you seem to make a big thing out of it “you and your costs should be separate from me and my costs, is practically unenforceable” You have been lecturing us on this subject without end and without enlightenment. You have had nothing to say.
You do try to elevate your status by talking about how you lead others by the finger as if you are some master of a 19th century plantation. Well jeez boss I donna need you to teach me about life and teach me how to pick cotton through that there Socrates method. I’m the one picking it and you don know what cotton look like.
For a person that doesn’t “give a flying rat’s tail about your ideology” you sure do ask a lot of questions about it.
“But you do have the advantage of being oblivious to irony, and I must say that I envy that bliss.”
This I understand. I’m not oblivious to irony. You sometimes have a problem communicating and irony is a form of communication.
“How will you isolate Peter’s costs to Peter?”
In the interest of moving this discussion along let me help you out here. I don’t have to isolate Peter’s costs to Peter just as I don’t have to obligate Paul to pay for Peter’s foolishness. Not every action requires a reaction.
” don’t have to isolate Peter’s costs to Peter just as I don’t have to obligate Paul to pay for Peter’s foolishness.”
Come on. Tell me how will you obligate Peter to pay for his retinal detachment so that his costs don’t diffuse to Paul(s)? I challenge you to answer this question.
I ask ‘how will you achieve a goal?’ You answer ‘I will achieve the goal.’
Think a little, old chap. Think. How do you make someone pay for their meal in a restaurant? How and why is healthcare different?
“For a person that doesn’t “give a flying rat’s tail about your ideology” you sure do ask a lot of questions about it.”
It’s called curiosity. You should try it as well. It does wonders.
(I did promise you I was not going to give up on you on this one. I’m keeping my promise!).
I may be blissfully simple minded, but it seems simple in this case: allan and paul simply do nothing. Voila! Other cases will bring in more murkiness and may lead to a discussion of societal obligations to the disabled or poor….but lets defer that to get to Peter’s case as that will help establish principles.
Peter then has to decide…..he may live with his one bad eye, he may pay to have it fixed, he may seek charity care….or he can sue the bungee cord maker.
One might argue that the law suit costs are socialized….but this really is pretty much a one time cost….as once case law is settled the lawyers will no longer take on any similar cases.
It seems you see contracts as part of the answer. Please explain: contracts between which parties and saying what? I will wait for your answer in the allan/saurabh dialogue, but would prefer to hear your analysis right off.
You have become repetitious so for simplicity sake I will copy the previous answer to your ‘How?’hoping to spur you to provide your long awaited answer.
“How will you isolate Peter’s costs to Peter?”
In the interest of moving this discussion along let me help you out here. I don’t have to isolate Peter’s costs to Peter just as I don’t have to obligate Paul to pay for Peter’s foolishness. Not every action requires a reaction.
(Another straw man argument “ I ask ‘how will you achieve a goal?’ You answer ‘I will achieve the goal.’ ” What above indicates that we have the same goals? In this case nothing need be done.)
“Peter then has to decide…..he may live with his one bad eye, he may pay to have it fixed, he may seek charity care….or he can sue the bungee cord maker.’
Do nothing only works when:
a) everyone is paying out of pocket for medical care, That is no insurance.
b) no one is forced to treat Peter for free.
But if the above conditions are not met Peter’s costs will diffuse to the Pauls. Because the place that is forced to treat for free will raise the price for Pauls. So Peter’s costs will diffuse to Paul.
But let’s say that no one is forced to treat Peter for free, and Peter can’t afford the treatment, so the hospital writes it off. Now again the hospital will raise the prices for Pauls and Peter’s costs will diffuse.
But our situation is more complex because there is insurance and Peter may have insurance as may Paul.
It is for this scenario that I have repeatedly been asking allan how will he stop Peter’s costs from diffusing to Paul. He is adamant that he won’t make Paul pay.
“Not every action requires a reaction.”
In other words Peter and Paul are so separate that Peter’s actions are limited to Peter.
This brings us to the same question. How will you achieve and enforce this separation?
Or, how will you stop Peter’s costs from diffusing to Paul?
“(Another straw man argument “ I ask ‘how will you achieve a goal?’ You answer ‘I will achieve the goal.’ ” What above indicates that we have the same goals? In this case nothing need be done.)”
JHC! Do you not know the difference between a strawman argument and an allegory, metaphor and simile???! Sorry allan, I can only instruct you on one topic at a time, so I’m going to have to pass on this one.
“JHC! Do you not know the difference between a strawman argument and an allegory, metaphor and simile???!”
Am I now supposed to prove to you that what you are saying is pure garbage because you can’t defend yourself on the real issues? When did you stop beating your wife?
Saurabh, you continue to create a false dialogue pretending to paraphrase my words because you could find no such quotes. You should be careful because some might accuse you of lying. I think you believe too hard in your own words to actually understand what another is saying.
In the future quote my words and don’t paraphrase. Keep quotes in context and stop changing the premise.
“In other words Peter and Paul are so separate that Peter’s actions are limited to Peter.”
Must the actions be so separate? Must every action have a reaction?
“It is for this scenario that I have repeatedly been asking allan how will he stop Peter’s costs from diffusing to Paul. He is adamant that he won’t make Paul pay.”
Saurabh you keep saying the same thing though you have been corrected before. I won’t obligate Paul to pay for Peter’s foolishness. That is different than Paul being excluded from payment. I demonstrated this before when Peter’s foolishness injured Paul and thus Paul paid in many ways. (see several responses above) I suggest you refer to a dictionary and research the word ‘obligate’ and the phrase ‘I won’t obligate’. The word and phrase have nothing to do with what happens to those costs. There is a type of butterfly effect that better explains what you have been unable to state in a clear concise manner.
“Do nothing only works when:
a) everyone is paying out of pocket for medical care, That is no insurance.
b) no one is forced to treat Peter for free.”
There is no C or D? There are a lot of problems entailed in this statement Saurabh makes in response to Paul. What does the word ‘works’ mean? If it works 99% of the time does that mean it works or doesn’t work?
a) is wrong. Everyone paying out of pocket doesn’t mean treatment and sometimes treatment is a necessity no matter who pays. One can’t permit an Ebola patient to roam the streets and expect no one else to become infected.
Even b) suggests failings of the authors understanding of the subject at hand.
There are too many distortions and logical fallacies in Saurabh’s arguments.
“Am I now supposed to prove to you that what you are saying is pure garbage because you can’t defend yourself on the real issues? When did you stop beating your wife? ”
Good lord. This the smartest statement I have read on this blog from you allan!
“You should be careful because some might accuse you of lying”
Oh dear! The satirically-challenged allan, devoid of an atom of irony, is offering me advice.
allan, I honestly believe reports of your cerebral inertia are slightly exaggerated but I should advise you that your pretending to be acephalic is a poor arguing technique.
“There is no C or D?”
“Even b) suggests failings of the authors understanding of the subject at hand.”
“a) is wrong. Everyone paying out of pocket doesn’t mean treatment and sometimes treatment is a necessity no matter who pays.
Except (a) is conditionally independent of the necessity of treatment. This is what is called a strawman argument.
Here is a little test for allan.
allan, if someone says you are spewing crap that is:
a) Strawman argument
c) Misrepresentation of crap
d) Lies about crap
e) All of the above.
“I won’t obligate Paul to pay for Peter’s foolishness. That is different than Paul being excluded from payment.”
How will you prevent Peter’s cost from diffusing to Paul?
This is my question. You still haven’t answered it.
(I am rather enjoying this, as I am enduring a boring conference, so thanks for the distraction)
“One can’t permit an Ebola patient to roam the streets and expect no one else to become infected.”
You are finally seeing the light. This is the neighbourhood effect. But I won’t tax you too much by asking you to apply the same principles to one’s choices and the healthcare consequences of those choices.
Saurabh, what you call satire is merely your methodology of altering what other’s have said. Stop the not so hidden insults and get on with the discussion.Your former bright lights are dimming as is your prose. Presently your responses are like the graffiti seen in a public bathroom.
“How will you prevent Peter’s cost from diffusing to Paul?”
This was answered multiple times. I can’t and I might not want to because the unintended consequences of doing so might be worse than the consequences of doing nothing.
“(I am rather enjoying this, as I am enduring a boring conference, so thanks for the distraction)”
I have to say Saurabh that your replies are quite dull. But, they are like the soap opera on TV. One can’t put it down because they are waiting for some enlightenment that never comes. I note you have’t walked out of your conference. Based upon your recent postings It sounds like you left your seat and walked into the bathroom.
“This is the neighbourhood effect.”
One day you will learn that not all Neighborhood effects are the same and need be treated identically. Until you learn that I guess we will have to live with the dull non productive thoughts we have been reading.
Probably best for me not to jab your thin skin. As it seems to blunt your synapses.
But you have given me an anchor. Hallelujah!
“I can’t and I might not want to because the unintended consequences of doing so might be worse than the consequences of doing nothing.”
Might you be suggesting that the transaction costs of internalizing Peter’s costs to Peter might not be worth it?
“One day you will learn that not all Neighborhood effects are the same and need be treated identically.”
I love nuance. Enlighten me, old chap.
Saurabh, jab away all you want, my synapses are all intact, but need some stimulation even the low level stimulation you have been providing. You can even be impolite.
I adjust my replies to reflect the tone of the one on the other side. I am still waiting for that truth of yours that will clear up all the issues, end climate change, defeat ISIL and clean up all the toxic waste dumps. You inform me that “But you have given me an anchor. Hallelujah!”. Finally a bit of light is coming into your darkness so you ask:
“Might you be suggesting that the transaction costs of internalizing Peter’s costs to Peter might not be worth it?”
“Might you be suggesting that the transaction costs of internalizing Peter’s costs to Peter might not be worth it?”
Phew! ‘Depends’ is concordant with ‘might.’ For a moment I thought I lost you again.
What might those transaction costs be which might determine the worth it factor of trying to internalize Peter’s costs to Peter?
PS 1: note my use of ‘might’ twice. I’m giving you considerable latitude.
PS 2: you are tantalizingly close to epiphany. Hang in there chum!
“What might those transaction costs be which might determine the worth it factor of trying to internalize Peter’s costs to Peter?”
Too many factors to consider, but from what we know today we would be better off not obligating Paul to pay for Peter’s foolishness. Of course you are waiting to spring your plan on us that I believe some of us have known (the generalized nature) from the onset. I can tell you now if it involves coercion, which it probably does, or involves us obligating Paul to pay for Peter’s detached retina even in a diffused contractual fashion then we will not agree. This lack of agreement has been obvious since post #1 out of 64 so to play the type of game you are playing is quite juvenile. I have to deal with children of all ages so I am used to it.
“but from what we know today we would be better off not obligating Paul to pay for Peter’s foolishness.”
From a utilitarian perspective, were I to be honest, I’d have to agree with you.
Utilitarian is a long run metric. Policy is not made with the long run in mind. You can argue that it should be. But it’s not.
Nor is policy made with the “greatest good for the greatest many” in mind.
Which means that the costs of internalizing Peter’s costs to Peter, in the short run, is less than the benefits of those costs being internalized, in the short run.
Which was the point I made in the first post.
I was never arguing against the moral force of your argument, but its practical implementation.
I think we are done with this topic.
“Which was the point I made in the first post.”
Much ado about nothing.
You were hit by the Arrow of asymmetry and left with empty short quips.