• Why do we pay for pills, but not exercise?

    The NYT recently had a piece covering a BMJ study on how exercise is as effective as medications in preventing death from a number of causes. My latest column at CNN Opinion talks about this in detail, and ask why our health care system is so willing to pay for the latter, but not the former.

    Read it.


    • That’s a massive pet peeve of mine. I’m only an anecdote, but in my case, the available meds did not do much (on bloodwork numbers, not mortality), and exercise did more. One thing perhaps lost in aggregated A vs B studies is that though A and B may have the same effect on a group, individually, one may work better than another. Thus, even if medication and exercise are about the same in aggregate, because A works for some and B works for others, and people are assumed to do what work and not do what doesn’t, making both available will lead to better outcomes (and we know that this happens at least once, because I am an example).

      An additional failure to subsidize occurs if you look into people who incorporate exercise into their daily commute, for example walking to the train or bus stop, or biking to work some or all days per week. This may or may not be cheaper than a gym membership(*), but inserting it into a daily routine is a good way to avoid slacking off. If someone decided to save gasoline (**) with the purchase of a hybrid or plugin automobile, there is (or was, for years) a hefty subsidy. But moving from 25mpg to 50mpg, on a baseline of (say) 10000 miles per year, saves all of 200 gallons of gasoline per year. Electing to ride a bicycle for 2500 of those miles instead of driving the 25mpg car, saves 100 gallons of gasoline per year. I’d love to have gotten 1/2 of the e-car subsidy back when I bought my bike.

      And over the years, it’s even been possible to observe a dose-response curve — some summers I put in many miles on my bike, and the weight goes down a few pounds. Some winters are especially unfriendly to cycling, and the weight goes up a few pounds.

      (**) I’m aware of the energy costs of food production. Most of the people who make that argument are either intentionally misleading or misled by the bright-shiny of apparently non-intuitive results. Lots of food that we eat has a fossil fuel energy cost within a factor of 2 of its calorie cost. At 1:1, a bicycle gets about 600mpg. What kicks up the average is mammal flesh and some varieties of seafood, where the if energy cost is 10:1 or even 100:1. Most of the very-expensive food is eaten for protein, and at least in my case, when I am hungry from exercise I am not interested in filling the gap with protein, and it would not be healthy either.

      (*) If you regularly walk as part of your commute, you’re going to want comfortable shoes if you can afford them, and you’re going to wear them out. Similarly, if you’re going to bike to work, especially at all times of year and in all weather, you’re not necessarily going to be happiest on a cheap bike. And good “utility bikes” in this country are still a niche purchase, and thus not as cheap as they could be (and are, in other countries).

    • I love this discussion.

      I wonder though if you have any policy/delivery system recommendations based off what you are describing here in the article. It almost seems like the next logical step would be for payers to test models which pay people for exercising, or perhaps penalize them for not. They sort of do this through discounts on gym memberships and there is a neat app called GymPact which sort of does this too. The more conservative (and also a lot of behavioral econ people) I talk to seem to like this sort of thing, but the more liberal folk point out, rightfully so, that this could unfairly lead to selection and effect rating and premiums for some people who just can’t exercise; case in point being that gym membership discounts are about selection, not really saving an insurance company money through better health.

    • Son was telling me that his employer’s insurance company is
      offering some dollar amount off the premium if you go to the gym 3
      days a week. He’d have to scan in at a designated gym, the credit
      would be lagged a month. Thinking of people on exercise cycles who
      read faster than they pedal I know it is possible to go to the gym
      and not workout very effectively. With the continuing march of
      electronics and connections I can imagine them increasing their
      credit to people who hooked up to a monitor and logged a heart rate
      in a heart conditioning range for a certain length of time. My
      feeling is that people who’re already prone to exercise would
      benefit but the non-exercisers probably wouldn’t sign up until
      they’d already had some health issue and run up a big

    • We also need a sleep mandate with a subsidy. Ditto for
      healthy sex, or would that qualify as exercise? We don’t subsidize
      those things because they would not advance the interests of the
      medical-industrial-drug complex. Amerikan medicine, don’t you know,
      is not there to improve the lives of patients, but rather the lives
      of fat cats.

    • Are doctors really paid more to write a prescription? Who
      is suppose to be paid for exercise? The patient should be able to
      go out for a walk for free or get a cheap aerobics video.

    • Allow insurance companies unlimited latitude to discount
      premiums in accordance with the actuarial benefit associated with
      particular levels of fitness and we’d have an automatic method for
      incentivizing exercise.

    • An additional bit of data on exercise and costs. The Dutch
      spend about 30 Euros per capita per year on their quite-nice
      bicycle infrastructure. There are places where that won’t work —
      West Virginia is hilly, Houston is hot, and all the “big squareish
      states” have lots of driving and low density. But there are places
      where that should work; the New York metro area is smaller than the
      entire Netherlands, yet contains more people. Similarly, Denmark is
      larger than Massachusetts, yet contains fewer people. A similar
      analysis applies for transit and the associated walking to/from
      stops. Show-my-work for comparisons to Netherlands and Denmark:
      By-zip-code US cumulative population distribution:
      Dutch annual costs per capita:
      Note that in addition to pills and electric vehicles, we also
      subsidize parking. It’s not a matter of whether we have socialism
      and government economic meddling, it’s instead whether we’re doing
      it right.

      • “we also
        subsidize parking. It’s not a matter of whether we have socialism”

        Socialism is a federal matter. Subsidized parking is a local matter. There is a big political difference.

        • #1, I was unaware that these terms were only applicable to government at a particular scale, so I disagree with your distinction. I checked my dictionary, it used words that were distinctly scale-neutral (“community”).

          #2, It’s not just parking; about half the cost of building and maintaining roads comes from taxes not tied to automobiles or fuel.

        • State governments couldn’t be socialist? What will Single Payer in Vermont be then?

    • I note everyone mentions gym membership, but I exercise
      more with an exercise machine at home. It takes less time, it’s
      cheaper, and I can be around if waiting for a repairman, the
      laundry to finish, the bread to rise, etc. And I’ve belonged to
      gyms where you can spend your hour lounging by the pool, working on
      your tan, finishing off with a sauna and shower. Nice, but not
      exactly improving fitness.

    • Great points made. Funny how exercise is a preventative of
      a lot of things, yet people only see it from an aesthetics point of

    • My health insurance plan effectively subsidizes my gym
      membership. Some payers already do pay for exercise.

    • The experience of wellness programs would seem to be
      relevant here. Search this blog for plenty on that. Prepare to be
      disappointed by how much good they do.

      • The tube here (NHK, the government sponsored channel)
        claims to have done a study in which the _only_ thing they found
        that correlated with reduced medical care costs for people in
        full-time employment was participation in a weekly sport-like
        activity. Bowling, badminton, table tennis, walking with a group.
        Anything, as long as it was more physical than sitting and you
        actually got out and did it. The idea that participation in a group
        activity is good for you is something I’ve not noticed in a US
        context, where everything is about individual activities. And I
        don’t even know if the Japanese even do more of this than
        Americans. But NHK seemed quite convinced that group activities had
        a real effect on reducing medical care expenditures.

      • Wellness programs that work:
        Stop smoking. Don’t drink to excess. Don’t use illegal drugs. Prevent morbid obesity. Don’t drink or otherwise be impaired when driving a car or doing anything else that can cause harm.

    • ” Every time a doctor writes a prescription, he or she probably earns some money. ”

      That statement has all sorts of implications, but was left unexplained so one can imagine a gigantic plot. That is a problem with articles of this nature. It is the type of statement that shouldn’t be made without explanation. One could just as easily say the author reaped benefits by including this type of incomplete statement because it sounds shocking and that creates a desire to quote the article increasing the number of hits which equates to money.

    • I think it quite dumb to pay for exercise; I get plenty of exercise mowing, planting, remodeling and cabinetmaking. I can’t wait for insurance to start subsidizing these.

    • Because exercise is free!

    • #1) I can’t figure out why you disagree with my distinction. There is a difference between federal and state funding. I am sure you understand that and understand the meaning of federalism.

      #2) Maybe we should have more toll roads. Maybe we should have less roads. There are a lot of maybe’s but there is a distinct difference between federal and state spending.

      As far as revenues for maintaining the roads, that is really hard to pin down though I believe that inflation has negatively impacted revenues and road travel is probably subsidized. The question arises, why should the federal government subsidize road travel on non federal roads. Another question is, are the federal interstate highways paying for themselves??