Resource Type: Research Briefs & Reports

The information in this report is intended to provide educational information on the cost-effectiveness of sugary drink excise fees.

Executive Summary

Continually rising rates of obesity represent one of the greatest public health threats facing the United States. Obesity has been linked to excess consumption of sugary drinks. Federal, state, and local governments have considered implementing taxes on sugary drinks to reduce consumption, reduce obesity, and provide a new source of government revenue.^1-3 A fee on sugary drinks is a similar strategy to increase the price of sugary drinks, improve health, and provide revenue.

We modeled implementation of a state fee on sugary drinks at fees of $0.03/ounce, $0.02/ounce, and $0.01/ounce. This report summarizes the results of the $0.01/ounce fee. Results for additional fee rates can be found in Appendices 1 and 2 (please see pages 15 and 16 in the PDF of the report).

The $0.01/ounce fee is projected to be cost-saving and result in lower levels of sugary drink consumption, thousands of cases of obesity prevented, and tens of millions of dollars in health care cost savings. The fee is projected to save $3.05 in health care costs per dollar invested.

Background 

Although consumption of sugary drinks (defined as all drinks with added caloric sweeteners) has declined in recent years, adolescents and young adults in the United States consume more sugar than the Dietary Guidelines for Americans 2020-2025 recommend, with persistent racial/ethnic disparities.^4-6 According to recent estimates, 56% of adults and 63% of youth in Hawaii report drinking soda.^7-8 The percentage of adults in Hawaii who report drinking soda varies by racial and ethnic group, with more consumption reported by Native Hawaiian, Other Pacific Islander, and Black residents and less consumption reported by Chinese, Japanese, Filipino, and White residents.⁷ On average, teenagers in Hawaii consume more sugary drinks than other age groups, and nearly half of Hawaii teens (46%) drink one or more sugary drinks per day.⁹ Public health researchers have suggested that excess intake of sugary drinks may be one of the single largest drivers of the obesity epidemic in the U.S.¹⁰ An estimated 57% of adults and 28% of youth in Hawaii have overweight or obesity.^8,10

Targeted marketing contributes to differences in consumption levels by income level. People who live in low-income areas are more exposed to advertisements for sugary drinks than those who live in high-income areas.¹¹ Exposure to advertisements may influence sugary drink consumption levels in these communities, as low-income consumers on average consume more sugary drinks than higher income consumers.¹²

Consumption of sugary drinks increases the risk of chronic diseases through changes in body mass index (BMI), insulin regulation, and other metabolic processes.^13-14 Randomized intervention trials and longitudinal studies have linked increases in sugary drink consumption to excess weight gain, diabetes, cardiovascular disease, and other health risks.^13-14 There are persistent racial and ethnic disparities across both sugary drink consumption levels and rates of obesity and chronic disease.^4-6 In light of this evidence, the Dietary Guidelines for Americans 2020-2025¹⁵ recommend that individuals limit their sugary drink intake in order to manage body weight and reduce risk of chronic disease.

Targeted pricing strategies have emerged as one recommended strategy to reduce consumption of sugary drinks.¹⁶ This strategy has been studied by public health experts, who have drawn on the success of tobacco taxation and decades of economic research to model the estimated financial and health impact of a sugary drink tax.^17-20 In Hawaii, rising costs of health care and insurance premiums are impacting businesses under Hawaii’s Prepaid Health Care Act.²¹ Passage of a sugary drink fee has been discussed as an effective strategy to reduce Hawaii’s health care costs.^21-22 Public poll results in Hawaii show that there is support of a sugary drink fee as an approach to reduce obesity.²²

This report aims to model the projected effect of a Hawaii sugary drink fee on health and disease outcomes over a decade. All drinks with added caloric sweeteners were considered subject to the fee, while 100% juice and milk products were considered exempt. The fee would be reflected in the posted price of sugary drinks, similar to an excise tax.

MODELING FRAMEWORK: How fees on sugary drinks can lead to better health

A state fee is linked to change in BMI through change in sugary drink price and consumption   

How does a fee on distributors affect the price paid by consumers?

Since the cost of a sugary drink fee is incorporated directly into the beverage’s sticker price, a fee structured like an excise tax will likely influence consumer purchasing decisions more than a comparable sales tax that is added onto the item at the register. We assume 100% pass-through of the fee over 10 years and assume the fee would be adjusted annually for inflation. Our pass-through rate estimate is supported by empirical studies of excise taxes in Mexico and France that demonstrate near-complete pass-through rates to consumers.²³ Short-term studies for the local tax in Berkeley indicate imperfect, or less than 100%, pass-through.^2,24-25 The Hawaii Department of Health used an existing tool²⁶ to collect beverage price data from 257 venues in Hawaii, including 74 supermarkets, 74 grocery stores, 90 limited-service venues, 18 fast food restaurants, and one gas station/convenience store. Retail prices were weighted by national share of purchase and consumption.²⁶ The weighted price of sugary drinks in Hawaii was $0.07 per ounce. For example, a $0.01/ounce fee would raise the price of a 12-ounce can of soda from $0.84/can to $0.96/can.

How does increasing the price of sugary drinks change individual sugary drink consumption?

To estimate current sugary drink consumption levels in Hawaii, we adjusted national estimates from the National Health and Nutrition Examination Survey (NHANES) 2011-2014 by race and ethnicity group using reported adult sugary drink consumption from the 2014 Hawaii Behavioral Risk Factor Surveillance System²⁷ and youth sugary drink consumption from the 2012, 2013, and 2017 Hawaii Rethink Your Drink Study.²⁸ How much consumers will change their purchases in response to price changes is called price elasticity for demand. We assume for every 10% increase in the price of sugary drinks, there will be a 12% reduction in purchases (a mean own-price elasticity of demand of -1.21).²⁹ Recent research on the Berkeley, CA $0.01/ounce tax found a 21% reduction in sugary drink intake among low-income populations consistent with this estimate.^24,30-33

What are the individual health effects of decreasing sugary drink consumption?

Research has shown that decreasing sugary drink consumption can have positive effects on health in adults and youth. We estimated the impact of a change in sugary drink intake on body mass index (BMI), accounting for dietary compensation, based on rigorous studies identified in evidence reviews.²⁰ The relationship among adults was modeled based on the range of estimated effects from four large, multi-year longitudinal studies, which indicated that a one-serving reduction in sugary drinks was associated with a BMI decrease of 0.21 kg/m2 to 0.57 kg/m2 in adults over a 3-year period.^14,34-36 Among youth, we used evidence from a double-blind randomized controlled trial conducted over 18 months, which found that an additional 8-ounce serving of sugary drinks led to a 2.2 pound greater weight gain.³⁷

Reach

This strategy applies to all youth and adults in Hawaii. However, the model only looks at the effects on those 2 years of age and older.*

*BMI z-scores were used in our analyses, which are not defined for children under 2 years of age.

Cost

We assume the fee will incur start up and ongoing labor costs for fee administrators in the Hawaii Department of Health. To implement the strategy, the Hawaii Department of Health would need to process fee statements and conduct audits. Businesses would also need to prepare fee statements and participate in audits, which would require labor from private fee accountants. Cost information was drawn from the Hawaii state bottle recycling program and localities with planned or implemented fees on soft drinks.^20,38 The cost and benefit estimates do not include expected revenue from the fee.

CHOICES Microsimulation Model

The CHOICES microsimulation model for Hawaii was used to calculate the costs and effectiveness over 10 years (2017–27). Cases of obesity prevented were calculated at the end of the model period in 2027. The model was based on prior CHOICES work,^20,39 and created a virtual population of Hawaii residents using data from: the U.S. Census, American Community Survey, Behavioral Risk Factor Surveillance System,⁴⁰ NHANES, National Survey of Children’s Health,⁴¹ the Medical Expenditure Panel Survey, multiple national longitudinal studies, and obesity prevalence data provided by the Hawaii Department of Health. Using peer-reviewed methodology, we forecasted what would happen to this virtual population with and without a sugary drink fee to model changes in disease and mortality rates and health care costs due to the fee.

Results: ^$0.01/ounce State Fee on Sugary Drinks

Overall, the model shows that a sugary drink fee is cost-saving. Compared to the simulated natural history without a fee, the fee is projected to result in lower levels of sugary drink consumption, fewer cases of obesity, fewer deaths, and health care cost savings greater than $30 million over the 10-year period under consideration.

The estimated reduction in obesity attributable to the fee leads to lower projected health care costs, offsetting fee implementation costs and resulting in net cost savings. The difference between total health care costs with no strategy and lower health care costs with a strategy represent health care costs saved; these savings can be compared to the cost of implementing the fee to arrive at the metric of health care costs saved per $1 invested.

Results for additional fee rates can be found in Appendix 1 ($0.02/ounce fee) and Appendix 2 ($0.03/ounce fee). Please see pages 15 and 16 in the PDF of the report.

Uncertainty intervals are estimated by running the model 1,000 times, taking into account both uncertainty from data sources and virtual population projections, and calculating a central range in which 95 percent of the model results fell.
All metrics reported for the population over a 10-year period and discounted at 3% per year, unless otherwise noted.
*Not discounted.

There are differences in sugary drink consumption and obesity prevalence by race and ethnicity in Hawaii. The CHOICES model used Hawaii data to build a virtual Hawaii population. Without any strategy:

Sugary drink consumption is highest in the Native Hawaiian and Other Pacific Islander populations

Obesity prevalence is highest in the Native Hawaiian and Other Pacific Islander populations

Results: ^$0.01/ounce State Fee on Sugary Drinks By Race and Ethnicity Groups

Uncertainty intervals are estimated by running the model 1,000 times, taking into account both uncertainty from data sources and virtual population projections, and calculating a central range in which 95 percent of the model results fell.
All metrics reported for the population over a 10-year period and discounted at 3% per year, unless otherwise noted.
*Not discounted.

SNAPSHOT IN 2027

Cases of obesity prevented in Hawaii from a ^$0.01/ounce state fee on sugary drinks by race and ethnicity group*

Some groups are projected to experience larger declines in consumption of servings* of sugary drinks per person in Hawaii in the first year of fee implementation

Impact on Diabetes

We estimated the impact of the fee-induced reduction in sugary drink intake on diabetes incidence for adults ages 18-79 years using a published meta-analysis of the relative risk of developing diabetes due to a one-serving change in sugary drink consumption⁴² as well as state-level estimates of diabetes incidence⁴³ and prevalence.⁴⁴ On average, each 8.5 ounce serving of sugary drinks per day increases the risk of diabetes by 18%.⁴²

In Hawaii, we estimated that the proposed sugary drink fee would lead to a 6% reduction in diabetes incidence in the sugary drink fee models. Impact on diabetes incidence was calculated over a one-year period once the fee reaches its full effect. Impact on diabetes was calculated based on summary results from the model, not directly via microsimulation.

Impact on Tooth Decay

We estimated the impact of a sugary drink fee on tooth decay cost using a longitudinal analysis of the relationship between intake of sugars and tooth decay in adults. On average, for every 10 grams higher intake of sugar per day, there is an increase in decayed, missing, and filled teeth (i.e. tooth decay) of approximately 0.10 over 10 years.⁴⁵ There are many studies showing a similar relationship between higher intake of sugars and tooth decay in children and youth⁴⁶ and thus we assume the same relationship as found in adults.

We used 2018 Hawaii Department of Human Services Med-Quest procedure code⁴⁷ data to estimate a Medicaid cost of treating tooth decay as: $234 for a permanent crown on Oahu or $562 on neighboring islands, and $39 for a filling on Oahu or $55 on neighboring islands. These codes reflect treatment for one surface and do not reflect higher reimbursement rates for multi-surface treatment, temporary crowns, or potential flat fee schedules. Based on analysis of data on tooth decay, fillings, and crowns for the U.S. population from NHANES 1988-1994 (the last year crowns and fillings were separately reported),⁴⁸ we estimate that 78.9% of tooth decay in children and 43.5% of tooth decay in adults are treated. Using this same data set, we estimate that 97% of treatment for children is fillings and 82.5% of treatment for adults is fillings.

To estimate Medicaid-specific savings in costs of dental treatment, we used state estimates of the numbers of people enrolled in Medicaid and CHIP and the proportion receiving Medicaid dental services. Because of limited Medicaid dental coverage for adults in Hawaii, only children are included in the Medicaid-specific calculations. In Hawaii, we estimated that a $0.01/ounce fee would lead to a total of $173,000 in Medicaid savings over a period of 10 years due to a reduction in treatment of tooth decay. The Medicaid reimbursement fee estimates may underestimate the total cost savings of tooth decay treatment projected here as dental providers may charge higher amounts to patients.

Expected Yearly Sugary Drink Fee Revenue

The annual revenue from a state fee on sugary drinks is likely to be substantial. According to the Rudd Center Revenue Calculator for Sugary Drink Taxes⁴⁹ a $0.01/ounce fee in Hawaii could raise as much as $42.9 million in 2020.

Actual fee revenue may be lower than these projected estimates due to several factors. The Rudd Center Revenue estimates are based on regional sales data adjusted for state or city specific demographics;⁵⁰ sales data for specific states and/or cities within those regions may vary from the regional average. Retailers may have inventories of sugary drinks obtained before the fee was implemented. There may also be some distributors/manufacturers that are non-compliant with the fee. The Rudd Center notes that their revenue projections “should be adjusted downward by 10% – 30%.”⁴⁹

Considerations for Health Equity

Concerns have been raised regarding the impact of the fee on households with low-income, because lower-income populations tend to consume more sugary drinks.¹² Economic studies indicate that with a sugary drink tax, consumers will buy less of these products.²⁹ This change in purchasing is substantial, so that consumers can be expected to spend less on sugary drinks after a fee is implemented. Using sales data from the Rudd Center Revenue Calculator for Sugary Drink Taxes,⁴⁹ along with local price data,^26,28 we project that individuals and households in Hawaii will spend less money on sugary drinks after a $0.02 per oz fee: about $104 less per year per person, and $314 per year less for an average household. This would free up disposable income for other consumer purchases. A typical consumer in Hawaii who continues to consume these beverages after the fee is in place would be expected to pay fees of about $2.50 per week, or $129/year.

In addition to these changes in spending, health benefits are projected to be greatest among low-income individuals. We project that more health benefits from this policy will accrue to low-income consumers; the same is true for a number of racial and ethnic groups. As noted above, in Hawaii, the percentage of adults who drink one or more soda per day varies by racial and ethnic group.⁷ Under the proposed fee, we project that Native Hawaiian, Other Pacific Islander, and Filipino Hawaii residents would see more cases of obesity prevented than expected for the average Hawaii resident. On that basis, the proposed fee should decrease disparities in obesity outcomes and improve health equity.

These expected changes in consumption and health outcomes have led economists to conclude that low-income populations benefit substantially from sugary drink taxes.⁵¹

Implementation Considerations

Revenue raised from a sugary drink fee can be reinvested in low-income communities. For instance, in Berkeley, CA, sugary drink fee revenue has been allocated for spending on school and community programs, many serving low-income populations or communities of color, to promote healthy eating and diabetes and obesity preventions.⁵² Public support for such fees generally increases with earmarking for preventive health activities.⁵³

There is opposition from the food and beverage industry, which spends billions of dollars promoting their products.⁵⁴ Relatively small beverage excise taxes are currently applied across many states. The proposed fee is likely to be sustainable if implemented based on the successful history of tobacco cigarette stamp excise taxes. There is potential for a shift in social norms of sugary drink consumption based on evidence from tobacco control tax and regulatory efforts.⁵⁵ This shift in norms can be facilitated by assessing sugary drinks, which reduces the attractiveness of non-caloric beverages and discourages consumers from selecting any sugary drink options when making beverage decisions.

Conclusion

We project that the proposed fee policy will prevent thousands of cases of childhood and adult obesity, prevent new cases of diabetes, increase healthy life years, and save more in future health care costs than it costs to implement. Savings in future health care costs would lead to a slowing of rising health care premium costs for employers and individuals across Hawaii. Revenue from the fee can be used for education and health promotion efforts. Implementing the fee could also serve as a powerful social signal to reduce sugar consumption.

Citation

Irvin L, Inoue K, Bowie A, Ching L, Starr R, Ryan J, White BS, La Chica T, Gortmaker SL, Long MW, Ward  ZJ, Giles CM, Barrett JL, Resch SC, Greatsinger A, Garrone ME, Tao H, Flax CN, Cradock AL. Hawaii: Sugary Drink Fee [Report]. Hawaii Department of Health, Hawaii Public Health Institute, Honolulu, HI, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; March 2021. For more information, please visit www.choicesproject.org

The design for this report and its graphics were developed by Molly Garrone, MA and partners at Burness.

Funding

Funded by The JPB Foundation. Results are those of the authors and not the funders.

For further information, contact choicesproject@hsph.harvard.edu

Appendices

Results for additional fee rates can be found in Appendix 1 ($0.02/ounce fee) and Appendix 2 ($0.03/ounce fee). Please see pages 15 and 16 in the PDF of the report.

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The information in this report is intended to provide educational information on the cost-effectiveness of sugary drink excise taxes.

Executive Summary

In California, health disparities and inequities persist for specific subsets of the population – the reasons for this are deep-seated and multi-faceted. Sugary drink consumption is one health behavior for which disparities exist, and it has been linked to excess weight gain, obesity, and the incidence of type 2 diabetes, heart disease, and cancer. Federal, state, and local governments have considered excise taxes on sugary drinks to reduce consumption, reduce obesity and associated chronic disease, and provide a new source of government revenue.^1,2,3 In California, statewide legislative measures to introduce sugary drink excise taxes have been proposed for a number of years in efforts to improve the health of Californians and reduce inequities, but none have passed.⁴

We modeled the implementation of a state excise tax on sugary drinks in California at a tax rate of $0.02/ounce. CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2020-2030) of implementing a tax with the costs and outcomes associated with not implementing a tax.

The tax modeled is projected to be cost-saving (that is, the tax saves more in future health care costs than it costs to implement even absent the potential revenues). The tax is projected to decrease sugary drink consumption among California residents, prevent nearly 200,000 cases of obesity, and save more than 1.8 billion dollars in health care costs. People who consume sugary drinks are expected to spend less on these drinks with the tax in place. We also project that non-Latino Black/African American and Latino California residents will experience even greater health benefits than the average resident after the tax is implemented. These results are summarized below and in the complete report.

Background 

In California, health disparities and inequities persist for specific subsets of the population – the reasons for this are deep-seated and multi-faceted including systems that perpetuate the unequal distribution of power and resources along racial lines.⁵ Overconsumption of added sugars is common, with more than half of the United States population ages two years and older exceeding the daily recommended limit for added sugars put forth in the 2015-2020 Dietary Guidelines for Americans.⁶ Sugary drinks (defined as all drinks with added caloric sweeteners) are the number one source of added sugars that Americans consume.⁶

According to recent estimates, 40% of California residents drink at least one serving of sugary drinks daily.⁷ Higher than average sugary drink consumption levels are common among Latino and Black/African American Californians.⁷ In 2018, the beverage industry spent $1 billion to advertise sugary drinks in television, digital platforms (internet and mobile), radio, magazines, newspapers, coupons, and outdoor venues in order to drive preferences and purchases of unhealthy beverages.⁸ Beverage companies frequently target their sugary drink advertising towards youth, and are more likely to target Black/African American and Latino youth. Additionally, Black/African American and Latino populations are less likely to be the audience for marketing of healthy drinks like water.⁸

Strong evidence links increased consumption of sugary drinks to higher risk for obesity and other diseases that are tied to what people eat, such as type 2 diabetes,^9,10 and the prevalence of these diseases is higher among people with lower income and Latino and Black/African American Californians.^7,11 An estimated 37% of adults¹¹ and 21% of youth¹² in California have obesity. If current trends continue, 42% of adults in the state will have obesity by 2030.¹¹

Taxes have emerged as a promising strategy to reduce consumption of sugary drinks. In addition to the potential of a sugary drink tax to reduce obesity, it has cost implications as well. This report models the projected effect of a sugary drink excise tax on health, disease outcomes, and health care cost savings over the next decade.

Projected Impact of a Sugary Drink Excise Tax in California

We modeled implementation of a California excise tax on sugary drinks, at a tax rate of $0.02/ounce. All drinks with added caloric sweeteners were considered to be taxed, while 100% juice, milk products, and beverages with fewer than 25 kcals per 12 fluid ounces were considered exempt.

Results: What did we find?

We project that implementation of a state excise tax on sugary drinks only, at a tax rate of $0.02/ounce, has a 100% likelihood of being cost-saving. It will prevent more than 195,000 cases of childhood and adult obesity, prevent new cases of diabetes, increase healthy life years, improve health equity, and save more in future health care costs than it will cost to implement. Implementing the tax could also serve as a powerful social signal to reduce sugar consumption. Model results are presented as the most likely estimate as well as a likely range. The likely range is an uncertainty interval that is estimated by considering uncertainty from data sources and population projections and calculating a central range in which 95 percent of these model results fell.

How many people would be affected by the tax?

This can be thought of as reach or the number of people affected by the strategy. Based on our modeling, the table below presents the estimated number of people affected by the tax in the first year and the number of people affected by the tax over ten years.

The Likely Range is a 95% uncertainty interval estimated by running the model 1,000 times, taking into account uncertainty from data sources and population projections, and calculating a central range in which 95 percent of these model results fell.

What effect would the tax have on sugary drink consumption and spending?

Compared to projections of sugary drink consumption without a tax, the tax is projected to result in lower levels of sugary drink consumption. We project a 90% likelihood that individuals and households who purchase sugary drinks will spend less on sugary drinks after the tax is implemented, even though sugary drink prices will be higher with the tax. 

The Likely Range is a 95% uncertainty interval estimated by running the model 1,000 times, taking into account uncertainty from data sources and population projections, and calculating a central range in which 95 percent of these model results fell.

Average Annual Pre-Tax Sugary Drink Consumption Per Person in California by Race/Ethnicity

DATA SOURCES: California Health Interview Survey 2011-2017, NHANES 2011-2016, UConn Rudd Center for Food Policy & Obesity Sugary Drink Tax Calculator 2020; Analysis by CHOICES Project, 2020.
^✝Each serving is 12 ounces.

While Californians, on average, consume 251 servings of sugary drinks each in a year, higher than average sugary drink consumption levels are common among Latino and Black/African American Californians.

Post-Tax Decrease in Sugary Drink Consumption Per Person in California by Race/Ethnicity*

*In the first year following an excise tax of $0.02/ounce on sugary drinks.

^✝Each serving is 12 ounces.

With a tax, sugary drink consumption would decrease the most among Latino and Black/African American Californians. On average, each Latino Californian would reduce consumption by 85 servings per year and each Black/African American Californian would reduce consumption by 102 servings per year.

The Likely Range is a 95% uncertainty interval estimated by running the model 1,000 times, taking into account uncertainty from data sources and population projections, and calculating a central range in which 95 percent of these model results fell.
*Other includes people of Native Hawaiian and Pacific Islander, American Indian and Alaska Native, and two or more races.

What effect would the tax have on obesity and related health outcomes, overall and by race/ethnicity?

Compared to projections of obesity and related health outcomes without a tax, the tax is projected to result in fewer cases of obesity and fewer deaths over the 10-year period under consideration. Under the proposed tax, Black/African American Californians will experience a 39% higher than average reduction in obesity prevalence, and Latino Californians will experience a 33% higher than average reduction in obesity prevalence.

The Likely Range is a 95% uncertainty interval estimated by running the model 1,000 times, taking into account uncertainty from data sources and population projections, and calculating a central range in which 95 percent of these model results fell.
Costs and health outcomes are discounted at 3% per year, unless otherwise noted. Discounting estimates the present value of costs and health outcomes that are spent or received in the future, given that they are worth more today than they would be tomorrow.
*Not discounted.

Pre-Tax Obesity Prevalence in California by Race/Ethnicity

DATA SOURCES: California FitnessGram 2013-2017, NHANES 2011-2016, NSCH 2003-2018; Analysis by CDPH and the CHOICES Project, 2020.

Nearly half of Latino (43.5%) and Black/African American (43.6%) Californians have obesity, while smaller percentages of Asian (16.1%), White (33.2%), and Californians of another race (33.9%) have obesity.

Post-Tax Cases of Obesity Prevented in 2030 in California by Race/Ethnicity*

*With an excise tax of $0.02/ounce on sugary drinks.

A tax in California could prevent 198,000 cases of obesity in 2030. 58% of prevented obesity cases will be among Latino Californians, while they represent 42% of the population. 8% of prevented obesity cases will be among Black/African American Californians, while they represent 6% of the population.

The Likely Range is a 95% uncertainty interval estimated by running the model 1,000 times, taking into account uncertainty from data sources and population projections, and calculating a central range in which 95 percent of these model results fell.
Costs and health outcomes are discounted at 3% per year, unless otherwise noted. Discounting estimates the present value of costs and health outcomes that are spent or received in the future, given that they are worth more today than they would be tomorrow.
*Not discounted.
^✝Other includes people of non-Latino ethnicity and Native Hawaiian and Pacific Islander, American Indian and Alaska Native, and two or more races.

How much would the tax cost to implement?

There are initial and ongoing costs to implementing the tax. To implement the strategy, the California Department of Tax and Fee Administration would perform several administrative activities, including identifying and notifying taxpayers, revising manuals and tax return documents and systems, processing tax statements, and conducting audits. Businesses would also need to prepare tax statements and participate in audits, which would require labor from private tax accountants. Cost information was drawn from tax programs that were previously implemented in California¹³ and from planned or implemented excise taxes on sugary drinks in other states and localities.¹⁴ The cost and benefit estimates do not include expected tax revenue (discussed below). Below we include annual and 10-year implementation costs.

The Likely Range is a 95% uncertainty interval estimated by running the model 1,000 times, taking into account uncertainty from data sources and population projections, and calculating a central range in which 95 percent of these model results fell.
Costs and health outcomes are discounted at 3% per year, unless otherwise noted. Discounting estimates the present value of costs and health outcomes that are spent or received in the future, given that they are worth more today than they would be tomorrow.

How much would the tax save in health care costs compared to what it costs to implement?

The estimated reduction in obesity attributable to the tax leads to lower projected health care costs, offsetting tax implementation costs and resulting in a net cost savings. The difference between total health care costs with no strategy and lower health care costs with a strategy represents health care costs saved; these savings can be compared to the cost of implementing the tax to arrive at the metric of health care costs saved per $1 invested.

The Likely Range is a 95% uncertainty interval estimated by running the model 1,000 times, taking into account uncertainty from data sources and population projections, and calculating a central range in which 95 percent of these model results fell.
Costs and health outcomes are discounted at 3% per year, unless otherwise noted. Discounting estimates the present value of costs and health outcomes that are spent or received in the future, given that they are worth more today than they would be tomorrow.

What would the impact of the tax be on Medi-Cal* spending?

Based on the projected reduction in adult obesity prevalence due to the tax (compared to what prevalence would be without the tax), adult obesity-related Medi-Cal expenditures in California are estimated to decrease. This does not include potential reductions in child obesity-related expenditures, and may be an underestimate if adults utilizing Medi-Cal have higher than average health care costs of obesity.¹⁵ A previous analysis found that 12.2% of adult Medi-Cal expenditures were due to obesity.¹⁶ We estimate that, in California, obesity accounted for $8.9 billion of $73.3 billion total adult Medi-Cal expenditures in 2019.^16,17 This assumes that 74% of all Medi-Cal payments are for adults.¹⁸ The state paid 37% of total Medi-Cal expenditures in 2019,¹⁷ so we estimate that the state paid $3.3 billion in adult obesity-related Medi-Cal expenditures.

*Medi-Cal is California’s Medicaid program

The Likely Range is a 95% uncertainty interval estimated by running the model 1,000 times, taking into account uncertainty from data sources and population projections, and calculating a central range in which 95 percent of these model results fell.
Costs and health outcomes are discounted at 3% per year, unless otherwise noted. Discounting estimates the present value of costs and health outcomes that are spent or received in the future, given that they are worth more today than they would be tomorrow.

What are the key cost-effectiveness metrics?

Since we project that the tax saves more in future health care costs than it costs to implement, there is a 100% likelihood that the tax would be cost-saving. 

Costs and health outcomes are discounted at 3% per year, unless otherwise noted. Discounting estimates the present value of costs and health outcomes that are spent or received in the future, given that they are worth more today than they would be tomorrow.
*There is a 100% likelihood that these metrics are cost-saving.

What effect would the tax have on diabetes?

Economic studies indicate that with a sugary drink tax, consumers will buy less of these products.¹⁹ A $0.02/ounce tax will decrease the consumption of sugary drinks and this has other health implications that we can estimate. In California, the proposed sugary drink excise tax would lead to a 7% reduction in diabetes incidence over one year once the tax reaches full effect. We calculated this impact on diabetes incidence using projected declines in sugary drink consumption, not directly via microsimulation.

What effect would the tax have on tooth decay?

In California, we estimated that a $0.02/ounce tax would lead to a reduction of 502,000 decayed, missing, and filled teeth among Medi-Cal* recipients and $39.5 million in savings to Medi-Cal over 10 years due to a reduction in treatment of tooth decay. For the entire California population, we estimated the tax would lead to a reduction of 1,620,000 decayed, missing, and filled teeth and $135 million in savings for all payers due to a reduction in treatment of tooth decay. The Medi-Cal reimbursement tax estimates may underestimate the total cost savings of tooth decay treatment projected here as dental providers may charge higher amounts to patients. Impact on tooth decay was calculated using projected declines in sugary drink consumption, not directly via microsimulation.

*Medi-Cal is California’s Medicaid program

Key Considerations for Health Equity

Concerns have been raised regarding the impact of the tax on low-income households, because lower-income populations tend to consume more sugary drinks.²⁰ Economic studies indicate that with a sugary drink tax, consumers will buy less of these products.¹⁹ This change in purchasing is substantial, so that consumers can be expected to spend less on sugary drinks after a tax is implemented. Using sales data from the Rudd Center Revenue Calculator for Sugary Drink Taxes,²¹ we project that individuals and households in California will spend less money on sugary drinks after a $0.02 per ounce tax: about $48 less per year per person, and $142 per year less for an average household. This would free up disposable income for other consumer purchases. A typical consumer in California who continues to consume these beverages after the tax is in place would be expected to pay tax of about $1.40 per week, or $73/year.

In addition to these changes in spending, health benefits are projected to be greatest among low-income individuals. We also project that greater health benefits will accrue among Latino and Black/African American California residents compared with White and Asian residents. Using data on sugary drink consumption in the CHOICES model, the average daily consumption of sugary drinks among people in California varies by race/ethnicity group (see pre-tax figures on pages 4 and 6). Under the proposed tax, we project that Black/African American Californians would see a 39% greater reduction in obesity prevalence than average, and Latino Californians would see a 33% greater reduction in obesity prevalence than average. On that basis, the proposed tax could decrease disparities in obesity outcomes and improve health equity.

These expected changes in consumption and health outcomes have led economists to conclude that low-income populations benefit substantially from sugary drink taxes.²²

Implementation Considerations

A $0.02/ounce statewide excise tax on sugary drinks in California could raise as much as $1.3 to $1.8 billion in annual revenue.²¹ Revenue raised from a sugary drink tax could be reinvested in communities with low-income. For instance, in Berkeley, CA, revenue from a municipal sugary drink tax has been allocated for spending on school and community programs, many serving families with low-income or communities of color, to promote healthy eating, diabetes, and obesity prevention.^23,24 Public support for such taxes generally increases with earmarking for preventive health activities.²⁴

There is opposition from the food and beverage industry, which spends billions of dollars promoting their products.²⁵ Relatively small beverage excise taxes are currently applied across many states. The proposed tax is likely to be sustainable if implemented based on the successful history of tobacco excise taxes. There is potential for a shift in social norms of sugary drink consumption based on evidence from tobacco control tax and regulatory efforts.²⁶ 

Modeling Assumptions and Summary of the CHOICES Microsimulation Model

How does an excise tax on distributors affect the price paid by consumers?

An excise tax is incorporated directly into a beverage’s shelf price. We assume 100% pass-through of the tax over 10 years and assume the tax rate would be adjusted annually for inflation. Our pass-through rate estimate is supported by empirical studies of excise taxes in Mexico and France that demonstrate near-complete pass-through rates to consumers²⁷ and consistent evidence in the U.S. indicating that beverage taxes increase prices, although there is some variation by store type.^28-31   

The expected change in sugary drink price was estimated based on national sugary drink prices³² and regional sales data for several categories of sugary drinks (i.e., soda, sports drinks, fruit drinks, energy drinks, sweetened teas, sweetened coffees, and enhanced water).²¹ In California, we assume the average price of sugary drinks is almost $0.09/ounce, so a $0.02/ounce tax would raise prices by 23%. This means that, for example, the price of a 12-ounce can of soda would increase from $1.06 to $1.30/can post-tax.

How does increasing the price of sugary drinks change individual sugary drink consumption?

How much consumers will change their purchases in response to price changes is called price elasticity for demand. We assume for every 10% increase in the price of sugary drinks, there will be a 12% reduction in purchases (a mean own-price elasticity of demand of -1.21).¹⁹ Recent research on the Berkeley, CA $0.01/ounce tax found a 21% reduction in sugary drink intake among populations with low-income consistent with this estimate.^33-37 In California, we assume a $0.02/ounce tax that raises prices by 23% would reduce purchases by 27%. We assume this 27% reduction in purchases results in a 27% reduction in consumption.

To estimate current sugary drink consumption levels in California, we used national estimates of sugary drink consumption from NHANES 2011-2016 adjusted to race- and ethnicity-specific estimates of sugary drink consumption among children, teens, and adults from the California Health Interview Survey³⁸ and estimates of sugary drink sales in California from the UConn Rudd Center for Food Policy & Obesity.²¹

What are the health effects of decreasing sugary drink consumption?

Research has shown that decreasing sugary drink consumption can have positive effects on health in youth and adults.

Assumptions about sugary drinks and obesity risk

We estimated the impact of a change in sugary drink intake on body mass index (BMI), accounting for dietary compensation, based on rigorous studies identified in evidence reviews.¹⁴ The relationship among adults was modeled based on the range of estimated effects from four large, multi-year longitudinal studies, which indicated that a one-serving reduction in sugary drinks was associated with a BMI decrease of 0.21 kg/m² to 0.57 kg/m² in adults over a 3-year period.^39-42 Among youth, we used evidence from a double-blind randomized controlled trial conducted over 18 months, which found that an additional 8-ounce serving of sugary drinks led to a 2.2 pound greater weight gain.⁴³

Assumptions about sugary drinks and diabetes risk

We estimated the impact of the tax-induced reduction in sugary drink intake on diabetes incidence for adults ages 18-79 years using a published meta-analysis of the relative risk of developing diabetes due to a one-serving change in sugary drink consumption⁴⁴ as well as state-level estimates of diabetes incidence from the CDC Atlas 2016⁴⁵ and prevalence from the California Health Interview Survey 2017-2018.⁴⁶ On average, each 8.5-ounce serving of sugary drinks per day increases the risk of diabetes by 18%.⁴⁴

Assumptions about sugary drinks and tooth decay

We estimated the impact of a sugary drink excise tax on tooth decay and tooth decay treatment costs using a longitudinal analysis of the relationship between intake of sugars and tooth decay in adults. On average, for every 10 grams higher intake of sugar per day, there is an increase in decayed, missing and filled teeth (i.e., tooth decay) of approximately 0.10 over 10 years.⁴⁷ There are many studies showing a similar relationship between higher intake of sugars and tooth decay in children and youth⁴⁸ and thus we assume the same relationship as found in adults. We used the Medi-Cal Dental Provider Handbook 2019⁴⁹ to estimate a Medi-Cal cost of treating tooth decay as: $278 for a permanent crown and $58 for a filling. These codes reflect treatment for one to four surfaces but do not reflect the actual frequency of multi-surface treatment among Medi-Cal recipients or for higher reimbursement rates due to temporary crowns or potential flat tax schedules. Based on analysis of data on tooth decay, fillings and crowns for the U.S. population from NHANES 1988-1994 (the last year crowns and fillings were separately reported),⁵⁰ we estimate that 78.9% of tooth decay in children and 43.5% of tooth decay in adults is treated. Using this same data set, we estimate that 97% of treatment for children is fillings and 82.5% of treatment for adults is fillings. To estimate Medi-Cal-specific savings in costs of dental treatment, we used estimates of the number of people enrolled in the Medi-Cal Dental Program in 2018.⁵¹

CHOICES Microsimulation Model

The CHOICES microsimulation model was used to calculate the costs and effectiveness of a tax in California over 10 years (2020-2030). We forecasted what would happen to a virtual population of residents in California with and without a sugary drink tax to model changes in disease and mortality rates and health care costs due to the tax. Cases of obesity prevented were calculated at the end of the model period in 2030. The model was based on peer-reviewed CHOICES methodology.^14,52-54 We created a virtual population of residents in California using data from: the U.S. Census, American Community Survey, Behavioral Risk Factor Surveillance System, NHANES, National Survey of Children’s Health,⁵² the Medical Expenditure Panel Survey, multiple national longitudinal studies, and obesity prevalence data provided by California Department of Public Health. Impacts on diabetes, tooth decay, Medicaid spending, and household spending on sugary drinks were calculated based on summary results from the model, not directly via microsimulation.

Of note, the CHOICES microsimulation model does not include annual revenue generation from a state excise tax on sugary drinks in any of the cost-effectiveness calculations. The Rudd Center Revenue Calculator for Sugary Drink Taxes estimates potential annual revenues from excise taxes on sugary drinks and is “intended to provide a rough estimate” for municipalities to consider.²¹ According to the Rudd Center,²¹ a $0.02/ounce excise tax in California could raise as much as $1.8 billion in 2020. Accounting for 10-30% non-compliance as the Rudd Center advises, annual revenue estimates range between $1.3 – $1.8 billion.

Citation

Gouck J, Whetstone L, Walter C, Pugliese J, Kurtz C, Seavey-Hultquist J, Barrett J, McCulloch S, Reiner J, Garrone M, Cradock A, Gortmaker, S. California: A Sugary Drink Excise Tax. California Department of Public Health, Sacramento, CA, the County of Santa Clara Public Health Department, San Jose, CA, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; March 2021. For more information, please visit www.choicesproject.org

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

Funding

This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

For further information, contact choicesproject@hsph.harvard.edu

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