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—Dr Natale's thoughtful letter addresses an important issue that I was unable to address due to space limitations.Let me raise some practical issues that Natale and other readers may wish to consider.First, how good is the evidence that higher premiums for smokers get them to stop, or that higher premiums deter people about to start smoking from doing so? How good is the evidence on other health behaviors, or on other disincentives such as higher deductibles? If the evidence is not persuasive, then there is no justification for charging more, except to take in more money.Secondly, even if the evidence is weak, there is another major argument, namely that people who choose higher-risk behaviors should pay for their correspondingly higher medical expenses. The question then is, how accurately do the higher premiums or deductibles reflect higher costs for that insurance year? How many subclasses would
Light DW. Risk-Related Health Insurance-Reply. JAMA. 1993;269(2):213-214. doi:10.1001/jama.1993.03500020047019