by Michael J. Pramenko, MD

Sadly, despite the highest per capita health care spending in the world, our statistical life expectancy in the U.S. has declined for three years running. It’s past time to address the issues of chronic disease at the root of this trend. But to do so, health insurance needs to take a few lessons from auto insurance. Auto insurance companies regularly offer discounts for safe driving. Conversely, traffic accidents and speeding lead to rate increases. In addition, reports that a DUI can increase an individual’s auto insurance rates anywhere from 80 percent to 371 percent.

Without these potential auto insurance policy rate increases, our roads would be less safe while being more expensive for the habitual safe and responsible drivers. Interestingly, nobody ever decries these traffic law and auto insurance policies as “nanny state” techniques.

Via commercial insurance, Medicaid and Medicare, rates and taxes rise for everyone because of the unhealthy behavior of some, while offering insignificant rewards for healthy behavior. This is a perfect recipe for financial unsustainability in any health care system, let alone within the most expensive one on the planet.

So what is the health insurance equivalent of speeding or driving under the influence of drugs or alcohol? More important, what happens to an individual’s health insurance premium for avoidable and well-established behaviorally related health problems? Other than some rate adjustments for smoking – nothing. Worse yet, as the total cost of care for a population increases from avoidable chronic disease states, health insurance rates increase for everyone. Plus, we pay more in taxes to fund Medicaid and Medicare.

The challenge in health insurance is to find a method to reward healthy behavior without driving up health insurance premiums for the chronically ill and those with unfortunate health-related events of no fault of their own.

We could offer relatively inexpensive health insurance to a healthy cohort of patients. Unfortunately, this policy would drastically increase health insurance rates for the sick and chronically ill. Given the extraordinary cost of health care in the United States, it is necessary to spread the cost of care over the majority of the population.

So how does a community, state or nation rise to the challenge and find a mechanism to reward healthy behavior while disincentivizing unhealthy behavior? An advanced society with affordable health insurance will boldly address this challenge.

The answer lies in the ability to utilize the health insurance equivalents of speeding or reckless driving.  Fortunately for us, the Centers for Disease Control (CDC) has already accumulated the necessary data. The CDC has identified the most costly behaviors relevant to health insurance: the use of tobacco, alcohol and sugar-based beverages. As per the CDC, the United States’ health care system spends over $700 billion per year treating acute and chronic disease related to the use of these products.

We must begin rewarding healthy behavior in health insurance. Currently, the cost of public and private health insurance includes the cost of caring for many chronic diseases caused by human behavior.  The public can smoke, vape, drink, chew, eat and ingest a well-documented variation of unhealthy products. Correspondingly, the price of health insurance increases for everyone.

This is why the largest physician organization in the state of Colorado has enacted policy that could help Colorado lead the nation in addressing the chronic disease epidemic. In November, the Colorado Medical Society voted to support increased taxes on alcohol, tobacco and sugar-based beverages as long as those taxes are used to address the high cost of health care by addressing chronic disease where it starts and by rewarding those who choose a healthy lifestyle. The Mesa County Medical Society led the charge.

The policy does not support taxes on these products if the revenue is allowed to go to the general fund. If revenue is used for prevention and reducing premiums, there is a healthy return on investment for a Colorado consumer who chooses a healthy lifestyle. It is a tax that is then returned to the well-deserved healthy consumer of health insurance.

This tax policy works like our traffic laws. Healthy living is rewarded while we simultaneously work to reduce the rate and ill effects of unhealthy behavior. At the same time, we preserve the insurance pools such that health insurance rates don’t go up for the chronically ill with “no-fault” health problems.

With enough support, Colorado could pilot this innovative health policy design for a nation in desperate need of more value per health care dollar.

To learn more – view Dr. Pramenko’s TED Talk: “Marketing Healthy Behavior,” at

Michael J. Pramenko, MD, is the executive director of Primary Care Partners. He is chairman of the Board of Monument Health and is a past president of the Colorado Medical Society.

Categories: Communications, Colorado Medicine, Opinion/editorial, Resources, Health System Reform