If an individual’s body mass index isn’t a purely personal matter, what is? We have the right to choose between healthy food or junk food, even if the latter is more likely to result in obesity and related health problems. But once our choices affect others, there’s a natural conflict between individual freedom and social responsibility. In a nation where rising health-care costs and diminished access to medical care are issues of grave concern, personal decisions are no longer strictly private. The treatment of obesity- and smoking-related disease is tremendously expensive, which in turns drives up health insurance premiums for everyone, as well as raising the costs for Medicaid, Medicare and health coverage for public employees.

These legitimate concerns have resulted in a raft of nanny-state proposals to shape the public’s dietary habits by taxing this food or that drink or by outlawing free toys that accompany unhealthy children’s meals at some restaurants. Such proposals raise inevitable questions of fairness and effectiveness. Does it make sense to tax a can of soda but not a fruit juice that contains more calories per cup and very little additional nutrition? In any case, there is much uncertainty about whether such tactics would have any effect on the country’s collective bulging belly.

We prefer the approach most recently proposed in Arizona, where officials hope to levy a $50 annual fee on some Medicaid patients who don’t take steps to improve their health. It is vague at this point how the proposal would work, who would be liable for the fee and under what circumstances; but some examples mentioned are obese patients who fail to follow their doctors’ plans for losing weight, smokers who shun programs to help them quit the habit or certain diabetes patients who ignore medical advice on lifestyle changes that would improve their lab results.

But there’s no way the state would save money in the short term with what some are calling a “fat tax.” Administrative expenses alone would be higher than the $50 fee. Instead, the program is expected to help Arizona’s bottom line over time, by reducing healthcare costs for those patients.

Private companies already are trying similar strategies, with financial incentives for employees who make the kinds of smart decisions that are associated with better health. Safeway, for instance, offers significant discounts on health insurance premiums to employees who don’t smoke and who maintain healthy weight, blood-pressure and cholesterol levels. The company reported that its per-person healthcare costs remained flat for four years during which such costs rose 38 percent for most companies.

There’s the inevitable complaint that some smokers and overeaters live long and healthy lives and yet would have to pay the surcharge. That’s true enough, but the statistics are against them, and that should be reflected in insurance costs. Smoking and obesity greatly increase the risk of chronic and life-threatening health problems that in many cases are preventable, including stroke, cancer, heart disease and diabetes. It makes sense to tie higher preventable risk to higher premiums. Not all rock climbers have serious accidents, either, but they still pay more for life insurance, when they can find it.

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