Human Limits

A few weeks ago I showed a couple of graphs on the relationships between income, happiness and life expectancy.   The graphs demonstrated what can be described as a diminishing returns relationship with more and more resources required to generate even modest improvements in either happiness or life expectancy with an eventual flattening of the relationships.   A similar trend exists for health care spending per person and life expectancy across the world.

Is the U.S. Underperforming?

A quick look at the graph above clearly suggests that the U.S. health care “system” is underperforming.   But before anyone jumps to that conclusion it is important to ask what the health care system has to do with broad based measures of public health like life expectancy?   The next graph is a summary by the King’s Fund in the UK from three studies that have addressed this topic.   The point is that in two of the three studies traditional health care is a minor (15-25%) determinant of health.   My personal take based on a lot thinking and reading on this topic is that the Mc Ginness 2002 breakdown (15%) is probably the most accurate of the three.   In this context, most of the life expectancy problem in the U.S. is about health behaviors and social circumstance as opposed to the health care system.   That having been said, there are plenty of ways to look at what is wrong with the U.S. health care system like uneven access to care, uncoordinated care, excess use of technology and high costs; but life expectancy per se is probably not a good metric.

Will a “Better” Health Care System Fix the Problem?

In the UK significant resources have been devoted to developing and improving access to health care and coordinating this care via the National Health Service (NHS).  There has also been an effort to make sure that only evidence based treatments are used and that technology is appropriately deployed.  While the fraction of the GDP spent on health care is much lower in the UK than in the US, costs have gone up dramatically in the past decade or two.   Has this worked?  The UK lags behind most of the EU15+ countries (the original 15 members of the EU, Australia, Canada, the USA, and Norway) in many indices of health in spite of the efforts of the NHS.  The graph below shows that most of the problem is related to life style and things like smoking, drinking, diet and exercise.   Again, things that are relatively independent of the health care system.

Life Expectancy and Women in the U.S.

In general life expectancy for women is a few years higher than for men.  However, recent evidence suggests that life expectancy for less educated and poorer women is actually falling.  This fall in life expectancy highlights the limits of health or medical care on public health and reinforces that it is all (or at least mostly) about choices, lifestyle and social circumstances.

Summary

The point of this post has been to try to dissociate some of the criticism of the U.S. health care system from these broad based markers of public health.   There is plenty wrong with health care in the U.S., but the real problems for the population as a whole are driven by a combination of personal choices and social forces that dwarf both the many negatives associated with our fragmented health care system.

I want to get back to issues associated with Medicare in specific and the demographics of aging in general.    Part of the reason for this is that the rate of increase in Medicare spending seems to be slowing a bit and that is leading at least some of our political leaders and commentators to suggest we pay less attention to the long term implications of Medicare spending for the U.S. Federal Budget and economy.   That having been said I want to make a few points that we should all be thinking about in terms of our own retirement planning, our kids and also friends and relatives who are older.

Point 1: The number of workers per retiree continues to drift downward.

The figure below is from the Social Security Administration and it shows both historical data and future projections for the number of workers per retiree.   The magic number here is that over the next 20 years, if nothing changes, this ratio is going to drift downward from about 3.4 to 1 and stabilize at roughly 2 to 1.   Medicare (and also Social Security) is ultimately a pay as you go plan.  So the question is how much can we expect younger workers to pay to cover benefits for older people?   This is especially interesting because for better off older people, we currently have a situation where younger people of modest and limited means are essentially subsidizing a large portion of their health care costs.   Is this a wise policy?  Is it fair?  Is it even ethical?

Point 2:  What Happens After the Baby Boomers are Gone?

I did a little thought exercise with my friend and colleague Bob Smoldt, an extremely experienced medical administrator, who has great expertise about all of the economic aspects of health care.  I asked Bob what is projected to happen after 2045 when about half of the baby boom generation (born between 1946-1964) will likely be dead.   My thinking was that once we are over the demographic hump associated with the baby boom, perhaps the number of beneficiaries would stabilize or drop and the 2 to 1 ratio would get better.  Here is an excerpt of his response:

“What happens after baby boomers are gone?  Does the problem get better?  It is quite interesting.    Here is what the latest Medicare Trustees Report (2012) projects:

Number of Medicare beneficiaries

• 2045 = 88.7 million
• 2055 = 93.3 million
• 2065 = 99.8 million

There is no decrease projected.  I assume this is at least partly because of expected increase in life expectancy.  So if you want to save entitlements by having the Baby Boomers die off — they better do so more quickly……

Ratio of workers (people paying the bill) to beneficiary

• 1970 = 4.6
•  2010 = 3.4
• 2030 = 2.3
• 2085 = 2.1

Workers per beneficiary levels off from 2030 – 2050 and then declines even further to 2.1.  I don’t know why Social Security is different, but they project workers per SS beneficiary going down to 1.9.   I was a bit surprised by this, but there is no magic bullet here. It just keeps getting worse — we will basically be at 2 workers per beneficiary “

Point 3: Potential Solutions.

It seems to me that these statistics are pretty hard to ignore and that sooner or later Medicare is going to have to be reformed.  Here are a couple of ideas about what to do that could be adopted alone or in combination.

• Raise the retirement age.  I have discussed this in detail before and challenged the idea that raising the retirement age is unfair to certain ethnic and socioeconomic subsets of the population with lower life expectancies.   The issue here is largely who makes it to 65 vs. survival after age 65.
• Means test benefits so that well off people get less.   This is an old idea and the link earlier in the post on younger people subsidizing well off older people discusses how this might work and includes adjustments for groups with lower life expectancies.
• The other idea is so-called premium support similar to what members of Congress get.   Here is a comparison of several proposed plans.   This idea has recently been derided as “VoucherCare” by liberal political commentators even though it was originally proposed by liberal think tanks.

Answers From Scandinavia?

Some conservatives love to make inflammatory comments about how President Obama is trying to turn the U.S. in to Western European style social democracy with a cradle to grave welfare state.  I have a different observation; countries like Sweden are in fact reforming their social welfare systems much faster that the U.S. is via things like raising the retirement age and going to defined contribution funding models.   The Swedes for all their alleged liberalism seem to be recognizing demographic reality and dealing with it.  While Sweden changes the U.S. is trapped in a vicious cycle of demographic denial.

As part of the political trench warfare over taxes, spending and the long term federal debt the next big hurdle is so called “sequestration” on March 1^st.  If the President and Congress can’t agree on a combination of spending cuts and tax increases then a series of automatic cuts will take place.  Behind all of this bickering is one simple fact.  Medicare and other federal health care spending has risen from a tiny fraction of the federal budget to about 20% and is slated to continue to grow as the baby boomers retire.   In this post I want to give you some background information via 5 slides that will be useful to frame later discussions about what to do about Medicare in specific and health care in general.   The figure below comes from the Senate Budget Committee and shows key trends and future projections as a % of GDP.   Also remember the U.S. spends a higher fraction of our GDP (about 18%) on health care than any country in the world.

Overall Health Care Spending

The next figure is from a White House report in 2008 (before Obamacare) and it shows what is projected to happen to total health care spending in the U.S. economy well into the future in the absence of significant “reform”.

An Unbiased Look at Medicare

For anyone want to take a deep dive into Medicare, the Kaiser Family Foundation has a series of slide shows on Medicare that cover almost every element of the program starting from the late 1960s.  That having been said, I want to share three of the more than 120 slides posted on their website.

Kaiser Slide 1: “The Government” Pays 50% of the Bill.

The first slide is for anyone who has any doubt about just how much of the nation’s health care bill is paid for by the “government”.  The magic number was roughly 50% in 2010 when you add up all programs (including employee benefits) at every level of government.  So everyone needs to accept the fact the government involvement in health care is here to stay and we need to focus on how to deploy these resources in smarter ways.

Kaiser Slide 2: Does Obamacare Bend the Cost Curve?

The next slide shows projected Medicare spending until 2019.  The top line was pre Obamacare and the bottom line includes assumptions about costs savings as a result of it.   The key point is that Obamacare does not move the needle that much.  Additionally, the continuous upward trend shown in the 2008 White House slide above suggests that the many efforts at cost containment since 1980 have had limited effects on the growth of spending.   In a later post I will discuss how much things like price controls, bundling, and potentially limiting access to technology have done so far when the “heavy hand of the Feds” has attempted to intervene to reduce the rise in health care spending (the short answer is not much).

Kaiser Slide 3: Medicare Spending is All Over the Map!

The final slide shows how average Medicare spending varies more than threefold depending on where someone lives.  The reasons for this variation have been debated and are complicated but overuse of services (e.g. doing things of little or no benefit to patients) is a major cause.  This data also suggests that if more conservative and coordinated practice styles were adopted nationally there could be substantial cost savings for the country with no decrement in the quality of care provided to patients.

Summary

Health care spending in general and Medicare spending are complicated and emotional topics.  The points I want to emphasize via the 5 slides above include:

• Spending is rising and the trends are not sustainable.
• The “government” is heavily involved in medical spending.
• There is wide regional variation in spending per patient that is not related to patient outcomes.

In future posts I will offer some ideas about what could be done to restrain government spending on medical care and help solve the long term budgetary challenges associated with these spending trends.  Believe it or not there is one federal program that is a relative model of efficiency.   More on that later, but there are models out there that work.

In several recent posts I have tried to provide some information about life expectancy and measures of public health that might inform the current debate on raising the eligibility age for Medicare and perhaps Social Security.  These posts focused on some basic facts about longevity trends over the last 50 plus years. I also highlighted differences in life expectancy for men and women and also the influence of race and socioeconomic on life expectancy.  Finally, I made the point that behavioral and other risk factors that operate throughout life need to be addressed if we want to narrow the effects of sex, race, and money on life expectancy.  In this data heavy post I want to focus on the future of longevity and ask what this might look like going forward.  One idea is that life expectancy is going to continue to rise, and the other idea is that as a result of the obesity epidemic and other factors it is going to flatten out.

What the US Social Security Administration says

The next four figures are from the U.S. Social Security Administration (SSA) and might be described as the “official” estimates from 2005 for what might happen to life expectancy in the future.   Here is a description of the first figure from the SSA report.

“The figure shows life expectancy at age 0, by sex and calendar year, based on period life tables. Rapid gains in life expectancy at age 0 occurred from 1900 through the mid 1950′s for both males and females. From the mid 1950′s through the early 1970′s, male life expectancy at age 0 remained level, while female life expectancy at age 0 increased moderately. During the 1970′s faster improvement resumed for both males and females. Life expectancy for males and females in the 1980′s improved only slightly with males improving more than females. In the 1990′s, life expectancy has remained fairly constant for females, increasing only slightly for males.”

The second figure is also from the same SSA report and shows trends and projections in life expectancy at age 65.

The third figure from the SSA report I want to show is about the age of the oldest of the old…….people who truly are one out of 100,000.   For those interested in the topic of extreme aging here is a link to a list of the oldest lived people in history.

The final figure is comparative survival curves from 1900 to 2100.  Here is a description of this figure from the SSA report.

“This figure presents the population survival curves based on period life tables for selected calendar years. Great strides were made in the twentieth century toward eliminating the hazards to survival which existed at the young ages in the early 1900′s. Very little additional improvement to survival rates is possible at these young ages. Survival rates at the older ages are projected to continue to improve steadily. Projected gains in the probability of surviving to age 90 during the next 50 years are about the same as experienced during the past 50 years. For age 100, projected gains are much greater than for the past. Figure 5 shows population survival curves based on period life tables for, from left to right, 1900, 1950, 2000 and projected years 2050 and 2100.

 Although the shape of the survivorship curve has become somewhat more rectangular (less diagonal) through time, it appears that very little additional rectangularization will occur because survival rates are already so high at the young ages and are expected to continue increasing at older ages. The so-called “curve squaring” concept, though appealing to many, simply cannot be supported by the mathematics of mortality. The age at which the survivorship curve comes close to zero, through the compounding of single-year probabilities of survival, has increased greatly during the twentieth century and will continue to increase, as further strides are made against degenerative diseases. That mortality rates are found to continue to decline, at every age for which adequate data are available, demonstrates that no absolute limit to the biological life span for humans has yet been reached, and that such a limit is unlikely to exist.”

Looking past the Social Security data

As I noted in my introductory comments, there are two basic ideas about the future of longevity.  The first idea is that life expectancy is going to continue to rise and that the curves above might be underestimating life expectancy in general and the fraction of people who make it to 100 or older in specific.  If this occurs the public policy implications for the funding of and eligibility for Social Security and Medicare are problematic at best and a demographic time bomb at worst.  Here is a quote from the article by Olshansky and colleagues:

“The cumulative outlays for Medicare and Social Security could be higher by $3.2 to $8.3 trillion relative to current government forecasts……….”

There are also concerns about the techniques used to make life expectancy forecasts for the Federal Government that might lead to underestimates over time.  The second idea is that life expectancy is going to decline due to obesity and other factors.   The people who take the position that life expectancy might fall are also concerned about the techniques used to make these forecasts and that they might lead to overestimates of projected changes in life expectancy.

Caveats & Conclusions about the future life expectancy and where this will lead

• Any changes in life expectancy are likely to be unequally distributed in the population at large.  They are more likely to be seen in educated, well-connected better off people.  Even in a country like Sweden where heroic steps have been taken to reduce health care disparities and inequalities, there are still health disparities and inequalities in life expectancy.
• The genetics of who makes it to 90 or 100 are not well understood and no obvious genetic markers that predict extreme old age have been identified.  There is also some evidence that none will emerge with further research.
• My personal opinion is that trends in life expectancy will be divergent with some people trapped in a cycle of lifestyle related diseases and low social autonomy.  There will be another group of long lived super guideline followers who will be generally well-educated and better off.  These people will also be physically active, non-smokes, relatively normal weight, moderate drinkers, and engaged in life.

In a post last week I reviewed data on life expectancy and implications for the retirement age especially in the context of proposed changes in the eligibility of Medicare.  Here is a link to a retirement age calculator for the U.S. Social Security system.   For those born after 1938 the age gradually increases to 67 for those born in 1959.   The retirement age for Medicare is currently 65, but up for discussion in the ongoing debates about the fiscal future of the U.S.

The idea driving the Medicare debate is that people are living far longer than they were when the program was started and thus an upward adjustment is needed to make Medicare demographically realistic and limit the explosive (and unsustainable) increases in costs for this program as the baby boomers retire.   Opponents of this idea point out gains in life expectancy have been uneven and that most of the gains have been in relatively well-off segments of the population.   There are also significant life expectancy differences based on race, education and sex (women live longer).   Thus, the idea is that raising the retirement age would be “unfair” to certain groups.   As I pointed out last time, no one ever brings up the general “unfairness” of these programs to men which I find a bit puzzling but will leave to the pundits to sort out.

The counter argument about the potential unfairness of raising the eligibility age for Medicare is that the real problem is what happens to or in the groups with lower life expectancy before age 65.   In other words, the differences in life expectancy in various subgroups for those who make it to 65 or older in pretty good health are less dramatic than the differences in life expectancy from birth data would suggest.   What follows are some examples of what happens to people before age 65 that might explain some of the socioeconomic differences in life expectancy.

Physical Activity

The figure below is from King County, Washington (Seattle) and shows data on the influence of income on “no physical activity in the last month”.    As I have pointed out repeatedly, physical activity is extremely protective against all sorts of problems and increases longevity dramatically.

Obesity

The figure below shows the influence of parental education on obesity rates in kids.   Similar data is available for adults.  In adult women those with more education and higher incomes are less likely to be obese.   In men the relationship is not as clear, but there is some evidence that better educated men are less obese the less educated men.   However, the bad news is that obesity has increased for both sexes and all socioeconomic and racial subgroups in the last 20 plus years.

Smoking

The figure below shows data on smoking rates by education (usually a close correlate of income) and how they have changed between 1954 and the 1990s.   Rates have fallen for all groups but most dramatically for the most educated people.

Social Stress

There is pretty good evidence that social status and what might be described as social stress and autonomy plays a role in the early mortality seen in less educated and lower socioeconomic status groups.   In other words, poor and less educated people have less control over their daily lives and that is stressful and bad for their health.  Social stress is also independent of traditional risk factors or access to care.  The figure below shows how job category/education affects cardiovascular mortality in civil servants in England.  The bar graph on the right of the figure is a “log-scale” so a bit distorted, but the overall picture is clear.  The article points out that:

The cardiovascular mortality rate over 7 years in 17 530 London civil servants was more than 4% among unskilled workers, compared with 3% among clerical workers, 2% among professionals or executives, and less than 1% among administrators. The presence of identified risk factors, including cholesterol level, blood pressure, and smoking, explained less than half of these differences. All of these persons were working at the onset of the observation period and had access to medical care through the National Health Service. Therefore, neither biomedical risk factors nor limited access to medical care can account for most of the differences, and the major component of differences in the risk for cardiovascular death remains.   We suggest an explanation based on lifestyle and behavioral considerations.

My bet is that the more educated and higher paid civil servants in the UK were much more likely to be physically active, watch their diets and otherwise comply with health guidelines and medical advice.

Summary

All sorts of issues including physical inactivity, obesity, smoking and social status/stress need to be addressed to reduce the effects of socioeconomic status, education and race on life expectancy.  However, most or all of these issues need to be addressed prior to the age of 65 to have much of an effect on life expectancy.   Most are also relatively independent of access to medical care.  Confusing these issues, with the eligibility age for and long term finances of Medicare is an example of a policy discussion bait and switch.

Much of the long term pressure on the finances of the Federal Government is being driven by rising expenditures on health care and pensions and much of this is being driven in turn by an aging population.  This has led to proposals to raise the retirement age especially for Medicare.   You will likely be hearing more about the retirement age as our political “leaders” try to figure out what to do next in terms of taxes and spending.

Here is a proposal from the conservative Heritage Foundation on this topic, but they are not alone and many “centrist” groups are proposing increases in the retirement age for Medicare.   This idea has been criticized by people like the economist turned political commentator Paul Krugman as unfair because the increases in overall longevity in the U.S. have been uneven and not shared by all socioeconomic and racial subgroups in the country.   Today I want to take a deeper data driven dive into this topic.

1.  The big picture.   In an earlier post on longevity I pointed out that in 1960 about 60% of men and 71% of women lived to age 65.  The men who made it to 65 then lived an average of about 13 years and the women who made it to 65 lived another 17 years.   In 2010 about 84% of men and 89% of women made it to 65.   The average man who makes it to 65 now lives another 16-17 years and for women it is about 19 years.   These changes are being amplified by the fact that the leading edge of the baby boom generation is reaching retirement age causing a further bulge in the aging population.  You don’t have to be a rocket scientist to realize these demographic trends are putting pressure on Federal finances.

2.  Differential Increases in Longevity and Socioeconomic Status.  I mentioned above that critics of the idea of raising the retirement age for Medicare point out that most of the gains in longevity have been in people that are relatively well off.   The graph below is from a study by the Social Security Administration and shows survival curves starting at age 60 for men comparing those born in 1912 with those born in the 1941.   The key observations are that: a)in 1912 there was not much difference in life expectancy between the top and bottom half of income distribution, b) the bottom half of the 1941 cohort does not look that different than either group from 1912, and c) that life expectancy at age 60 has really gone up for the better off men born in 1941.    There are lots of ways to slice and dice data like this but pretty much every way you do it comes out the same and gains in life expectancy have been greater for people who are better off.

3)     The race and education snapshot.  Below are a table and graph from summary data from the U.S. Centers for Disease Control in 2011.   The table shows life expectancy at birth, 65, and 75 in recent years.   What is interesting here is that the differences in life expectancy between Blacks and Whites at 65 and especially 75 are much lower than the projected differences at birth.   The other interesting thing to note is that Hispanics are higher than either Blacks or Whites in all of the major comparisons.   I interpret this in a couple of ways.   First, a big issue here is not what happens once people reach the standard retirement age of 65, but what is happening prior to age 65 especially in Blacks.  The other issue here is that women do better than men and I have not heard any of commentators claim that raising the retirement is unfair to men.

The next figure shows life expectancy at age 25 in 1996 and 2006 by education level and sex.   This table shows a couple of things including: a) educated people live longer and there is a dose response curve, and b) life expectancy at age 25 for less educated people has stagnated.   This figure also shows that women live longer than men at every level of education.

4)     A summary slide.   The figure below is a summary slide that shows the effects of race, sex, and education on life expectancy at birth.   These differences would likely exist at age 65 but be much smaller in terms of absolute years.   The article this figure was taken from indicates that some of these differences might be getting worse.

My take on all of this data.   There are all sorts of ways this data can be analyzed.  For the purposes of thinking about the retirement age a couple of things stand out.

• People as a whole are living longer but the gains have been uneven and influenced by sex, education, and race.  There are also probably pretty tight relationships between race, economic well-being and education.
• A lot of the problem is not about what happens when people reach age 65, but what happens before age 65.   People with lower socioeconomic status tend to have a host of behavior and risk factor issues that negatively influence their ability to make it to 65 and then do as well after age 65.   So the real issue here is how to address health disparities vs. the fairness of raising the retirement age.
• Many of the factors leading to health disparities like differential smoking rates, obesity, lack of physical activity, and violence have little to do with what we think of as traditional health care and will not be fixed if and when high quality health care is available to all.
• There is also an argument that people are retiring too early for economic reasons and that a lot of people are financially unprepared for the long life they are likely to live in retirement.   If raising the eligibility age for Medicare encourages people to work longer, maybe that is good for their own long term economic well-being as well as that of the country as a whole.

Closing comments.  The discussion about the fairness of raising the retirement age for Medicare has been marked by incomplete thinking about the data and is confusing the very real problem of what to do about health disparities based on race, education, and sex with the arithmetic of Federal finances.   Some of this discussion is being led by people with overtly political and personal agendas like Paul Krugman (who should know better) at the expense of a hard look at the facts.

Today’s post is brief and shows data on health care costs and physical activity in Medicare patients from about 10 years ago.

The figure shows average annual total health care costs for adults over age 65 who had either worked for General Motors or were spouses of former GM employees.    The subgroups in the figure are based on body mass index (a marker of obesity) and also those who were inactive (0/wk), active 1-3 times per week and active more than 4 times per week.   Over 40,000 people were involved in the study.   For each body mass index subgroup, health care costs were lower and there seemed to be a dose response effect.   In other words the most active people had lower costs than the moderately active people who had lower costs than the least active people.

While this data is interesting and certainly suggests that more activity equals lower health care costs, there are limitations.  For example, perhaps the most active people were simply healthier to begin with and as a result could be more active.   In future posts I will explore what is known about the effects of interventions that promote physical activity on overall population health and also health care spending.

Depending on who you believe any long term solution to the fiscal issues confronting the United States will include revenue increases of 800 billion to 1.6 trillion dollars over the next 10 years.   From what I can tell almost all of the discussion about how to raise that revenue focuses on what the well-off will pay.   Will their income tax rates be higher, will their deductions be lower, and will the tax code be revamped so that things like capital gains are taxed at a higher rate?  As someone interested in public health it seems to me that the revenue, and more importantly behavioral changes, associated with sin taxes should be considered in this debate.

• The Congressional Budget Office estimates that nearly 80 billion dollars could be generated over the next 10 years by increasing the tobacco tax by about 50 cents per pack.
• Obesity researchers and economists from Yale and the University of Illinois Chicago have modeled the effects of a 1 cent per ounce tax on sugary beverages and estimated that nearly 20 billion dollars per year could be generated (200 billion over 10 years).
• The alcohol tax as a percentage of the total cost of various forms of alcoholic beverages is much lower than it was in 1980.  If the alcohol tax was 30% of the pretax value of the beverage (it is currently about 10%),  a study by the Cato institute estimated that federal revenues would increase by 25 billion dollars per year (250 billion over 10 years)
• Demark recently repealed their so-called fat tax.   It was generating about 200 million per year in taxes on high fat foods for the Danes.   Extrapolate that to the U.S. which has about 60 times the population of Denmark and you get about 12 billion in revenue per year or 120 billion over 10 years.

All of this adds up to about 650 billion dollars of increased revenue over ten years.   Additionally, there is pretty good evidence that smoking rates, health problems associated with excessive drinking, and perhaps even obesity rates might fall if these taxes were enacted.      For example a 10% rise in cigarette prices typically reduces consumption by 4%.  The sugary beverage tax is estimated to reduce consumption by about 24%, and the alcohol tax is estimated to reduce consumption on the order of 10%.   These behavioral changes would likely have positive effects on health care spending over time. There are also economic arguments about improved productivity and increased spending in other parts of the economy that would flow from things like less smoking and drinking.

One of the major arguments against sin taxes is that they fall disproportionately on the poor.  However, the counter argument is that the positive behavioral changes associated with these taxes would probably disproportionately benefit the poor in terms of improved health over time and more money to spend on other things.   This is especially important because policies that promote positive behavioral health changes in the poor have been difficult to implement and results have been marginal in many cases.

The figure below is from an article on health disparities in 8 socioeconomic groups in the U.S. and shows the role of common behavioral factors in disease burden (for the record I would argue that they grossly underestimated the effects of physical inactivity).  These factors are typically higher in the socioeconomic and racial groups with the worst overall health and lowest life expectancy.  Increased taxes on tobacco, alcohol and foods contributing to obesity would clearly help reduce the burden from the top four or five causes.

As the article notes:

“Disparities in mortality across the eight Americas, each consisting of millions or tens of millions of Americans, are enormous by all international standards. The observed disparities in life expectancy cannot be explained by race, income, or basic health-care access and utilization alone. Because policies aimed at reducing fundamental socioeconomic inequalities are currently practically absent in the US, health disparities will have to be at least partly addressed through public health strategies that reduce risk factors for chronic diseases and injuries.”

That having been said, I would argue that sin taxes should be attractive to liberals concerned about racial and socioeconomic disparities for statistics like life expectancy and other measures of overall health.

Sin taxes should also be attractive to conservatives who typically espouse a preference for policies that promote personal responsibility.   Sin taxes would also help address the current conservative narrative about makers and takers because the increased taxes would tend to fall hardest on states that receive excess federal funds relative to the taxes they pay…..what might be described as “taker” states.

The changes in tax policy that will be made in the coming years have the chance to make things fairer, simpler, more transparent, and perhaps spur economic growth.   The ideas outlined above have the added advantage of improving public health, raising revenue, and perhaps driving health care costs down in the longer run.  Sin taxes also have the opportunity to address both liberal and conservative policy goals, so shouldn’t they be part of any solution designed to put our financial house in order?