According to MSNBC:
A small number of companies have linked health factors to what employees pay for benefits, but the practice is expected to grow now that some federal rules have been finalized, spelling out what's allowed by law. Employee advocates worry that other anti-discrimination laws such as the Americans with Disabilities Act won't cover the person who is 20 or 30 pounds overweight.
I can't think of one legitimate reason why people shouldn't be charged more for living an unhealthy life style. After all, the inflated health care costs are in large part due to peoples unhealthy life choices like smoking, drug use (drinking mainly) and obesity.
I would even go as far as to say that not only private insurance companies, but government supported programs like Medicare should be charging smokers and obese people substantially more. Of course if either the government or private businesses were to charge more for various risk factors they have to financially support programs to eliminate these same factors - which many of them do but perhaps not enough.
How was that rant? Piss anyone off? good good...
Medicine & Health
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I object, Steve. If you really want to solve the problem, you shouldn't be giving those people health care at all. The sooner they die, the sooner we can get on with helping people who give a shit about themselves.
Posted by: Brian | September 10, 2007 7:04 PM
People who are overweight are not necessarily living an unhealthy lifestyle.
Just like people with lung cancer aren't necessarily living an unhealthy lifestyle (yes, it is possible to get lung cancer as a nonsmoker).
It sounds to me like the article was referring to not treating people based on diagnosed medical conditions (e.g., obesity) rather than lifestyle choices. Just about as ethical as excluding rare childhood diseases that are costly to treat... it may allow better coverage for those that are covered (which is a good) but taken to extremes, insurance becomes worthless if it doesn't cover anything.
Posted by: Becca | September 10, 2007 7:12 PM
20 to 30 pound overweight is hardly obese.
Posted by: writerdd | September 10, 2007 8:05 PM
Steve, there just isn't the evidence that lower weight correlates with better health or longer life, that losing weight in and of itself leads to better health, and that losing weight, over the long run, is even healthy for the body. And the evidence that people can keep weight off if they "are just serious about it?" Non-existent.
Charging / discriminating against people based on their bodyweight, in and of itself, is piss poor science.
Posted by: jody | September 10, 2007 8:17 PM
And men! Filthy, sickly men, more prone to death and disease at all stages of life than women. Men who insist on living their unhealthy lifestyle should be charged higher rates too. If they don't want to pay more, they can always get snipped!
Posted by: kjupi | September 10, 2007 8:24 PM
I'm not sure what that means in this context. By "unrealistic," do you mean unreasonable or improbable or what?
In any case, how about making healthy (let's say thin, since we're already using weight as a proxy for health) people pay more into social security and pension funds, since statistically speaking, they'll be around longer after retirement to receive benefits?
Posted by: kjupi | September 10, 2007 8:41 PM
kjupi, men do have higher accident insurance rates, and young men have higher rates than older ones. As do people who have especially hazardous jobs. And women (who live longer) have higher pension insureance premiums. In Sweden at least, if you're a bike rider, you get a rebate if you agree to wear safety-tested bike jacket and pants (which equates to penalizing those who don't), and you pay more for having a bike with a higher power-to-weight ratio.
I would not suggest that obese people, or people with lung cancer should pay more. I would suggest it'd be entirely sensible for smokers to pay more, or people engaging in other behavior detrimental to your health. But for that the better instrument is probably taxing the unhealthy behavior directly, like a health-care tax on tobacco, snacks and soda, alcohol and so on, in direct proportion to how much the product adds to the nations health-care bill. Transfer that money directly yo the health-care system. That'd also make the economic tradeoff choice completely clear to people.
Posted by: Janne | September 10, 2007 9:14 PM
Hey writerdd, I just checked the BMI data. I'm only 5'2". If I weigh 135lbs, I'm just within "normal" weight. If I'm 30 pounds more than normal (165lbs), I'm obese.
BMI is a really goofy thing (although honestly, I would feel rather fat at 165lbs. not sure I couldn't be healthy though, hard to say).
Steve- what you are saying about obesity is akin to denying the individuals diagnosed with lung cancer insurance coverage. That is not the same as penalizing them if they don't get treatment as soon as they realize they have the disease.
The companies are doing this based on BMI, cholesterol and blood pressure. Aside from the aspect that these are in most ways poor predictors of health risk when viewed in isolation, these are not always controllable. People who are "healthy" by BMI standards, fitness tests and their own medical history can be on perscription drugs and *still* have high cholesterol. There are no data (I am aware of) to support the idea this subcategory of people are at increased risk for heart disease.
Also, I'm not in the medical field so I don't know specific costs of lung cancer. But I'm reasonably certain there are diseases it's cheaper to not seek treatment for, and die early of. It is not the goal of insurance to make sure people always choose the cheapest option.
Posted by: becca | September 10, 2007 9:23 PM
"people pay more into social security and pension funds, since statistically speaking, they'll be around longer after retirement to receive benefits?"
That's a retarded argument since people stop paying social security once they hit retirement age.
Posted by: anon | September 10, 2007 9:40 PM
... which is exactly why people who live longer after retirement are bigger drains on the system. Unless I'm completely misunderstanding the way social security works, that is.
That's true. I still don't know what Steve meant by "unrealistic" though.
I didn't know that. Is that the case in general, or are you only talking about Sweden?
Posted by: kjupi | September 10, 2007 10:02 PM
Way to write an entry that really gets people riled up!
I definitely see what you're saying, but as others have said it's just too hard to tell whether people are fat because of something they did (or didn't do) or whether they were basically born that way. I think that a better idea would be to follow what Janne suggested and tax the crap out of unhealthy products (which I guess they already do to some extent, but you could make it even worse.) The problem is that illegal drugs are illegal so you can't really regaulte how much they cost and you can't give that money back to healthcare. But we could seriously tax snacks, fats, sugars, etc in addition to alcohol and cigarettes. We could also keep offering more breaks to people who log hours at the gym (which blue cross/blue shield did for me at Penn -- if I went 150 times a year, which I did, they gave me a discount on my membership.)
Posted by: Katherine | September 10, 2007 10:40 PM
The biggest problem I can see with the "tax everything unhealthy" suggestion is that poor people, who are already screwed when it comes to health and eating, would be more screwed. The only foods they can really afford are McDonald's in the first place. It would be a lot better if they stopped eating that crap, but I feel like if you're going to tax it, you'll also need to offer more food-stamp-like opportunities for healthy foods only, and offer more fresh food options for poor people who live in areas that are way underrepresented in terms of good grocery stores and farmer's markets. These people also don't have cars that can take them to fancy grocery stores....
Posted by: Katherine | September 10, 2007 10:43 PM
Phillip Longman published an interesting article in Washington Monthly a couple of years ago, suggesting that the money being used to prop up benefits in a healthcare system that is already financially unsustainable, instead be used to bribe people into acting preventively and taking better care of themselves (sign me up!). The entire article provides an interesting, and from my viewpoint, a sensible perspective on where our healthcare system needs to be heading � it�s well worth reading. I have to admit, it's a more positive approach than penalizing overweight people for not taking affirmative steps to improve their health. http://www.washingtonmonthly.com/features/2003/0304.longman.html
While I'm uneasy about the concept of penalizing employees for engaging in risky behaviors such as regularly eating Krispy Kremes (the motivators should be structured as rewards for good behavior, not penalties for bad behavior), I have to confess (sadly) that the comments reflect a very low level of comprehension about the value of exercise and good diet in maintaining health. For example:
. . .just isn't the evidence that lower weight correlates with better health or longer life, that losing weight in and of itself leads to better health, and that losing weight, over the long run, is even healthy for the body. And the evidence that people can keep weight off if they "are just serious about it?" Non-existent.
While it has been said (I believe by Orac) that anecdotes are not data, I will share the anecdote that eating clean, exercising and losing fat has resulted in better health for myself. I'm serious about eating well and exercising - which has contributing to keeping my weight off. I would challenge the commenter to back any of this misleading stuff up with the citations and analysis, because personally, I think it's all crap.
20 to 30 pound overweight is hardly obese.
I'm not going to wave the BMI in front of you, because you think it's propaganda anyway (note: it's a screening method, useful for quickly identifying potential problems; it's not intended to be a precision tool). But, as someone who has lost 48 pounds over the past 6 years (from a man's 6 ft, 2 in frame), I think it's pretty easy to be obese with 30 pounds of excess weight.
In the end - it's not the weight that's important, it's what the weight signifies in terms of your physiology and metabolism.
Posted by: JLowe | September 10, 2007 10:48 PM
I direct you, Steve, to last week's New England Journal of Medicine. Its 'cover stories' were two studies re: bariatric surgery, one of which was a decade-plus-long retrospective surgery of various weight loss methods.
Everything - *everything* - except bariatric surgery, including full lifestyle interventions, psychotherapy, et al. failed to produce a change in body weight at the 15-yr. check-in. Generally, the final body-weight was +/- 2% base body weight, 15 years in - regardless of weight control method utilized, including those cases in which no method was utilized.
Bariatric surgery was the one and only method that showed a better than 2% improvement; variable banding showed an average of 14% reduction, and full gastric bypass 24%. Bariatric surgery is also still being studied: there *is* no data regarding its long-term safety, and as such it is ethically reprehensible to hold people over a barrel to receive it or have their health insurance costs raised. The chronically ill have enough problems paying their health bills.
In a situation where the evidence, for the time being, shows there is almost no possibility of correcting the problem - considering the variety of treatment methods attempted for the non-surgery group, I cannot imagine what you perceive as the proper "initiative" to take - at the current state of the art with the exception of surgery, your argument is essentially "force them to take a risky surgery or force eventually-chronically-ill people to pay up (possibly beyond their means)".
And not for nothing, the way you phrase your post - regarding taking the initiative to correct the problem, and in light of your apparent ignorance regarding the current lack of effective treatment methods for obesity - makes it seem less like an actual proscription for how to help the shuddering health care system than simply something shot from the hip to try and stir a controversy. That's inappropriate on SciBlogs; the rule is to be both controversial *and* well-informed and factually supported. The former without the latter is fluff.
Posted by: James Stein | September 10, 2007 10:50 PM
Hey Steve,
Why stop there. Why don't we do a genetic screening of all your relatives. Anyone ever get cancer. We'll double your rate. People in my family don't get cancer so why should I pay for you. You drink at all. You're more likely to be in an auto accident and have alcohol related health problems. I live a dry life so why should I pay for that too. It's insurance dude, chances are you're not going to use it. It's to mitigate risk. Live with it or don't be a part of it.
Posted by: Chris | September 10, 2007 11:07 PM
I know gastric bypass is a (relatively) risky procedure, but I'd always heard that banding is pretty safe. Do the NEJM studies say otherwise?
Incidentally, it's probably worth mentioning that right now, lots of insurance providers require eventually-chronically-ill people to "pay up" even if they *do* opt for bariatric surgery. It's treated as a last-resort procedure: if you're obese and not *already* ridden with serious weight-related illness, then you either have to pay for the surgery yourself or, if you're lucky, jump through a whole lot of administrative hoops to convince your carrier that you're not the statistical way-outlier for whom dieting is actually an effective long-term solution.
Now maybe this all has less to do with stupid attitudes toward fat people than with a general disinclination on the part of the (US) insurance industry to invest in preventative medicine. But then, when a thin person shows up with a serious illness that could have been prevented but for a stubborn insurer, they don't get raked over the proverbial coals for not "giving a shit about themselves."
Posted by: kjupi | September 11, 2007 12:19 AM
I remember back when I was a kid, my dad went on a rant once (as he was wont to do) about heroin. His position was that heroin should be legalized completely, and then the government should up the concentration until most irresponsible addicts has overdosed. Somehow I feel Brian (comment #1) would approve...
Posted by: Isaac | September 11, 2007 1:17 AM
hmmmm.. tense problems. "had overdosed" fixes them I think.
Posted by: Isaac | September 11, 2007 1:18 AM
Posted by: llewelly | September 11, 2007 1:29 AM
Hmmm. I almost agree, but then they can turn it around on us healthy folks. If they have to pay for their unhealthy choices, we'll have to pay more for our healthy choices involving sports injuries, etc. that they're not at risk for.
Posted by: Vaughn | September 11, 2007 2:24 AM
Steve
I can't run because my foot was mangled in a motocycle accident 25 years ago. I carry about 15kg too much weight. Clearly I should be penalised for that.
I smoke because I was addicted 35 years ago, and try as I might, I can't quit. I was not informed of this back then. Clearly I should be treated with disdain.
I have skin problems because I have been under stress for most of my life. This is obviously an unhealthy life choice.
To put it plainly, this is a dickhead viewpoint.
Posted by: John Wilkins | September 11, 2007 2:41 AM
I'll take the job of HMO beach-snoop, which will require me to travel from resort to resort noting down the particulars of anybody willingly submitting themselves to unhealthy amounts sun-exposure.
Posted by: csrster | September 11, 2007 6:45 AM
If people are allowed to choose whether or not to be part of an insurance program, and if there's some semblance of proportionality in the scheme of surcharges for heightened risk factors, then sure, let fat people and smokers and couch potatoes and... Type As and... poor people pick up the tab for their lifestyles.
Then reflect on the vagaries of life and grow a conscience.
Posted by: bob koepp | September 11, 2007 9:49 AM
Oops, forgot to add motorcycle as a major risk factor! Motorcycle fatality rates are way higher than regular car fatality rates per 100 million miles traveled. I'll update my list of unhealthy decisions, thanks!
Posted by: Brian | September 11, 2007 9:51 AM
Cars are a much worse risk than planes. Anyone who uses a car should be unable to get medical treatment in the event of a crash, because of a bad lifestyle choice.
Posted by: John Wilkins | September 11, 2007 10:18 AM
"smoking and driving are completely different. One is necessary... the other not at all."
This depends on what your, umm, lifestyle is....
Posted by: bob koepp | September 11, 2007 10:26 AM
I think there are fairly simple ways to at least chip away at this problem. This is just one, but I think it's the right sort of approach.
Some insurance companies are implementing programs in which employers can provide discounted health insurance if employees get regular health screenings, basic advice on health, fitness, and nutrition, and create personal wellness programs based on those suggestions. It's all relatively knew, as far as I know, so they're still exploring the best options, I imagine. One interesting thing, though, is that they've found disincentives to be quite a bit more effective than incentives (e.g. rather than discounted insurance rates for participants, they would have higher insurance for non-participants, though it amounts to the same thing).
Obviously such programs aren't perfect, particularly because of the difficulty of monitoring how well people stick with their wellness programs, nor will they come close to solving the whole problem. But it seems to be a step in the right direction that is based more on personal health screenings and habits rather than cruder indexes like BMI.
Also, I fail to see how taxing unhealthy foods necessarily penalizes the poor. It would at first, sure, and they could just keep buying it and digging themselves a deeper financial hole, but it could also just shift food their food-buying patterns from cheap crap to cheap good stuff. If people just cook for themselves and buy the separate ingredients (preferably the generic ones, in bulk), it's really, really easy to eat well and cheaply.
Posted by: Carex | September 11, 2007 11:25 AM
Just out of curiosity, in what way does smoking increase health care costs? Mind you, I know smoking's bad for you n' all.
Posted by: Brian | September 11, 2007 11:25 AM
Look at what was published today! Why Harvard Wants You To Be Unhealthily Thin:
It's difficult to exaggerate the extent to which the actual scientific evidence fails to support any of this [i.e., BMI of 25-30 is "a major contributor to morbidity and mortality"]. In fact, the current evidence suggests that what the Harvard crew is saying is not merely false, but closer to the precise opposite of the truth. For the most part, the so-called "overweight" BMI range doesn't even correlate with overall increased health risk. Indeed "overweight," so-called, often correlates with the lowest mortality rates. ... Furthermore, it's simply not known if high weight increases overall health risk, or is merely a marker for factors, most notably low socio-economic status, which clearly do cause ill health.
The article goes on to cite the 2005 JAMA paper by Katherine Flegal et al., which was denounced by the Harvard School of Public Health.
Posted by: The Neurocritic | September 12, 2007 2:12 AM
So stupid and ignorant people should be charged more for education, because it is harder and more expensive to educate them?
Posted by: Jonathan Vos Post | September 17, 2007 12:18 AM
You know...some of these comments posted on here are really ignorant! Not all big people are that way because of their lifestyles....there are also medical conditions that cause a person to put on and have difficulty losing extra weight such as an insulin resistance. It's easy for you to pass judgement and sit there and say that overweight people should be penalized for not "taking initiative" when you don't even know the situation. AND, health insurance nowadays is not all that affordable so if a person can't afford health insurance....there isn't really much they can do to treat their conditions.
Posted by: Nonya | January 24, 2008 11:33 AM
"Not all big people are that way because of their lifestyles....there are also medical conditions that cause a person to put on and have difficulty losing extra weight"
Such a small proportion of people with weight problems have real genetic/medical conditions that cause this difficulty. Nearly everyone can lost weight... energy in energy out. Eat less - exercise more, not everyone will be stick thin but give me a break everyone can be a HEALTHY weight.
Posted by: Steve | January 24, 2008 1:12 PM
Ignorance is not an excuse for problems losing weight. Accurate information about metabolism and the simple physics of weight-loss has been available for decades. If you CHOOSE to ignore it, you should pay more for health care.
Energy in, Energy out.
Posted by: Brian | January 24, 2008 1:34 PM
I gotta say... if it is so incredibly impossible for people not to be overweight, why are we in the middle of an epidemic of weight problems when just a generation ago we weren't? I mean, if it's so unavoidable you'd think it would have been a bigger problem for much longer.
It does piss me off that I can't get the care I need but other people get care for conditions they got themselves into. Seriously, where I live I can't get any coverage for problems with my reproductive system because they're considered "fertility related" (even though they are related to an ectopic pregnancy I had, which is potentially life-threatening) - but my obese neighbor can get all the health care she wants for her heart and cholesterol and blood pressure problems. How is that fair? I didn't do anything adverse to my uterus - she certainly can't say that about her arteries.
Posted by: Marie | January 24, 2008 4:05 PM
Some of these posts are really disturbing. I am a chunky chick, not huge but by no means skinny. I take vitamins, walk, drink lots of water & make sure to eat the recommendated amount of fruits daily. I am just not built to be skinny. Some people are just that way. Why is it sooo impossible for thin people to except that? Why are thin people sooo angry? Doesn't anger cause you to have heart problems that lead to heart disease? Shouldn't you then pay more for insurance since your soo angry at me because i love myself the way i am? Leave us big people alone! It's not our fault you choose to eat horrible tasting foods & spend your entire lives in a gym! If you love being thin so much then at least be thin & happy!!! And Carex have you ever been to an organic market? The prices are insane. Low income families could not possibly afford to shop at them. Also, what did taxing tabacco do? Nothing, everyone's still smoking!
Posted by: Janie | January 24, 2008 6:12 PM
that is your comment to my post? Well what about the rest? Did you do any "scientific" study on why thin people are sooo angry and miserable?
Posted by: Janie | January 24, 2008 6:37 PM
Janie, no one is telling you to eat special health-foods. You can keep eating junk food all you want, just don't eat so damn much of it! You'll save money, AND lose weight. "Energy in, energy out" means exactly what it says. Put in less than you put out and you'll lose weight. That's physics. It doesn't matter where the energy comes in from, and it doesn't matter how you put it out.
To answer your question, though, thin people (in this case) are miserable because they have to pay more for health care. That's the point of this whole post.
Posted by: Brian | January 25, 2008 12:39 AM
Brian, first of all i don't sit around and eat junk. As i said in my prior post i try to maintain a healthy lifestyle as much as possible. I do eat fruits, take vitamins, walk and drinks lots of water. You do not pay more because of me or any other over weight person. I am 28 so because i am in my child bearing years i have to pay more for health insurance even though i am happily married & don't plan on having children. But because of the women out there who can't get pregnant and need fertility drugs i am forced to pay more! Is it my fault you can't get pregnant? My ovaries are fine! I just don't want children right now. Also, what about all the "healthy" in shape people who are having heart attacks in the gym? You are more of a risk hiking in the damn mountains and riding your bikes where you shouldn't. What about all the rescue people we hear about who have to put their lives on the line b/c you choose to go hiking and get lost or stranded? Don't hate me because i love myself : ) Anger leads to heart problems! And we don't want those premiums to go up and have all you skinny people blaming us again : )
Posted by: Janie | January 25, 2008 10:27 AM
steve, my research is my life experiences. I am a happy go lucky love myself for who i am person. Don't hate be because of that! All my life thin people have been trying to make me hate myself and i refuse to let that happen. The common thin people line "oh your soo pretty but you would be soo much pettier if you lost weight".
Posted by: Janie | January 25, 2008 10:34 AM
Steve, No what i am saying is that all these posts are whining about how they have to pay more b/c of over weight people. Well why don't you factor in all the other issues why you may have to pay more. Like fertility issues, age. I work for a company where the majority of the employees are elderly so my premium is higher. Even though i'm 28 and i don't have any medical problem i have to pay more money do to this. But i am not blogging about how i can't stand elderly people b/c of this. I choose to work for this company and respect the fact that the other employees have medical issues & require our insurance.
Posted by: Janie | January 25, 2008 2:26 PM
Also, what about all of us over weight people who have to shell out our hard earned tax money to pay rescue workers? Why should i have to pay a rescue worker to rescue you because you deceided to go hiking in the woods and a snow storm struck? There are soo many different ways you can argue this. I don't smoke but many of my thin coworkers do and take 5-10min breaks at least three times a day. I don't take these breaks so should i demand my company to pay me more or them less? Stop blaming all the chunky people for all your problems.
Posted by: Janie | January 25, 2008 2:33 PM
1. I didn't state that smokers do not pay more for insurance. I stated that at my company my thin "healthy" coworkers are smokers and take 3 5-10min. breaks per day. I am not a smoker and i do not take these breaks. So they are being paid company time to take breaks when i am working.
2. People pay for their rescue? Since when? As long as i've been alive i was taught to dial 911. And the rescue workers who arrive are paid for by the government. I was not aware that thin people prepay for these rescues, if so then i apologize, but i doubt it.
3. Yes i will get old one day. That is why i said that i understand why i have to pay a higher premium at my company right now. I understand older people have more health conditions. As i said i am not whining about this issue. And i choose to work for a company even with the fact that i have to pay more.
4. Steve please read your own blogs or at least read mine before you answer them. Just because you went to some hot shot college does not make you better then anyone. You are ignorant with or without your degree. Show some compassion. Your attitude is one of the reasons the world is becoming so bitter.
Posted by: Janie | January 25, 2008 4:20 PM
nice
Posted by: kelp | January 28, 2008 4:13 PM