I still recall some morbid humor in conversations when I worked for Michigan Blue Cross in the 1960s. Someone had done an analysis that proved without doubt that the financially smartest thing employers could do if employees became injured on the job was to kill them (presumably cleverly enough so as to avoid criminal penalties). This was due to the fact, at the time, that their financial liability for an employee who was killed on the job was significantly greater than it cost them for the average employee injured.

To the best of my knowledge, this fact was never passed on to employers as an advisory suggestion, and I certainly know of none who practiced any such horrendous policy. But I recently noted that the same kind of morbid logic has been resurrected in a study of what happens to at least some employees and other individuals who are helped to become healthier. In the long run, this often leads to significantly greater lifetime healthcare costs – for the individual as well as the rest of us who share in the burden of paying for the healthcare each one uses.

It took Dutch researchers, perhaps because citizens there have far more choices about how unhealthy they can be (e.g. retail selling or free government provision of narcotics), and whether plus how they die, given euthanasia permission. In any case, these researchers found that lifetime costs for smokers and obese individuals, inflicted with the most commonly targeted health problems around, were significantly less than for their healthier counterparts.

The reasons for this were fairly simple. Smokers tend to get lung cancer, and die significantly younger than do non-smokers. This creates a situation where the average lifetime costs for the remaining years of life of 20-year olds in the Netherlands were over $400,000 each, versus only $321,000 for smokers, thanks to their seven-year shorter lifespan. Similar differences were found for obese individuals, whose higher risk of diabetes gave them an average lifespan four years shorter than healthy peers, and lifetime healthcare costs of only $365,000.

This means that governments in other countries, presuming they are guided by fiscal realities alone (or enough) could save between over $79,000 per citizen per lifetime across their populations if they let smokers adopt and persist in this addiction, while they could save at least $35,000 each for those it left undisturbed to become and remain obese. Governments could also gain additional revenue through higher taxes paid on tobacco products, if they let smoking balloon, or on unhealthy foods if they let everyone balloon to higher weight.

The difference between lifetime costs and costs per year on average are more likely to affect governments than employers or commercial insurers, since it is the higher number of years that older people incur significant healthcare costs, even if they lived healthy lives, that drives government expenses for Social Security and Medicare payments, or the equivalent on other countries. While the “one-horse shay” model of everyone living in good health until the last year of their life, then having everything go bad at once so that dying is not protracted could be the ultimate answer to this dilemma, no one has come up with a cost-effective way of telescoping sickness into the end of life alone.

In the meantime, it must be recognized that the long-term financial interests of governments will necessarily be in conflict with those of their citizens, in most cases, at least. Science fiction stories I read fifty years ago had answers to this dilemma, such as lotteries that dictated that a certain number of people over some healthy age level had to die each year, with imaginative devices similar to Hitler’s “final solution to the Jewish problem” for doing so. But this phenomenon surely indicates that we should not demand that all health policies and investments must be cost saving, since that would leave us with some rather draconian challenges.

Of course, there may be many policy analysts who will find this Dutch finding a persuasive argument for leaving it up to each individual whether each wants to live an unhealthy short life or a healthy long one. This would tend to make both smoking and obesity purely lifestyle choices, as opposed to national public health challenges. I suspect the argument will persist, regardless of the long-term financial consequences for governments and citizens, though it may add weight to the “free will” position.