Am I a brothers' keeper? The influence of lifestyle related diseases on solidarity in the Dutch health care.

Summary The prevalence of lifestyle related diseases is growing rapidly, and so do the costs of health care. A combination of these developments might put pressure on the solidarity and financing of health care. This thesis examines the influence of lifestyle related diseases and their costs on the solidarity in the Dutch health care. The main research question is: Do obesity- and smoking-related diseases and costs have a negative influence on the solidarity in health care? If so, to what extent and what are the potential implications and options for future health care financing? The prevalence of and costs attributable to obesity have grown in the past years and these numbers are expected to increase in the future. Between 2008 and 2009, 11.5% of the adults suffered from obesity in the Netherlands. Costs attributable to obesity are 2% of the total health care costs in 2003. The prevalence of smoking and the related health care costs have decreased over the past years. 27% of the 15 year-olds and older smoked in 2010. However, the costs due to smoking are still a substantial part of our health care costs, which was 3.7% in 2003. Lifestyle diseases as a consequence of obesity or smoking might influence the level of solidarity in the Dutch health care. The concept of solidarity has many interpretations. In this thesis it is defined as: “Solidarity is the feeling of reciprocal sympathy and responsibility among members of a group which promotes mutual support”. In the Dutch health care system, this is arranged by crosssubsidies; low-risk and high-income groups contribute to the high-risk and low-income groups (by an income dependent contribution and a community rate premium). In addition, every Dutch citizen has access to a broad range of health care service. Feelings of solidarity can be influenced by the level of individual responsibility in health behavior. In lifestyle related diseases, individual responsibility plays a greater role than in lifestyle independent diseases. As a result, the feelings of ‘reciprocal sympathy’ can differ for lifestyle related diseases. The empirical part of this thesis examines the willingness to pay (WTP) for people with a lifestyle independent disease and the willingness to pay for people with a disease related to smoking or obesity. The latter two are combined in the variable ‘lifestyle dependent diseases’, in order to measure the difference between willingness to pay for treatment. Respondents were asked what they were willing to pay for inclusion of a treatment for others, on top of the yearly costs for the basic health insurance. The mean willingness to pay for a treatment of a lifestyle independent disease is €24.96 and €7.26 for lifestyle dependent diseases, which is a significant difference. In sum, the respondents are willing to pay 3.4 times as much for lifestyle independent treatment than for lifestyle dependent treatment. This difference in WTP indicates a different level of solidarity between people with a lifestyle related disease due to smoking or obesity and a disease independent of lifestyle. This might have a consequence for the financing of health care: in the future people might not be willing to pay for health care costs of others. People with lifestyle related diseases become responsible for their own health care costs. There are several options for future financing. The composition of the basic benefit package can be changed by the government, so that treatments for lifestyle related diseases will not be reimbursed anymore. Lifestyle adjusted premiums are a second option. The third option is taxes on food (‘fat-tax’) and cigarettes, these taxes flow in to the risk equalization fund and can be used to compensate insurers. In addition, prioritizing people with a lifestyle independent disease for treatments is a option in which the different level of solidarity is expressed. Finally, healthy behavior can be rewarded and stimulated with a bonus-system. All options incorporate more individual responsibility than the current financing. In sum, lifestyle diseases related to obesity and smoking have a negative influence on the solidarity, which can have consequences for the financing of health care.