HOME / human nature: Science, technology, and life.

Big Brother Is Watching Your WeightYour tax dollars at work, penalizing fat people.

By William SaletanPosted Wednesday, Oct. 21, 2009, at 8:19 AM ET

Should fat people pay a penalty just for being fat?

Charging overweight policyholders more is a hot topic among private health insurers. The rationale is twofold. First, fat people are more likely to develop expensive health problems. Second, fat can be avoided or reduced through exercise and healthy eating. If we charge fat people more for health insurance—or charge thin people less, which amounts to the same thing—people will improve their habits.

RSS

Insurers have been moving aggressively in this direction. But as David Hilzenrath explains in the Washington Post, there are two different ways to implement such "wellness incentives." Some employers reward workers just for participating in wellness programs. Others peg their rewards to the bottom line. Hit the weight target, or you don't get the discount.

Incentives based on outcome, as opposed to incentives based on effort, are hugely controversial because weight loss is much easier for some people than for others. Biological factors such as genes make some of us more susceptible to weight gain. So do environmental factors such as poverty. That's why some liberals are upset about the health reform bill approved last week by the Senate finance committee. The bill lets insurers increase financial incentives (i.e., penalties) based on weight and other outcomes. A union official tells Hilzenrath that such incentives are insurance discrimination "based on preexisting conditions."

Actually, the bill offers plenty of protection to policyholders who have trouble losing weight. It bars private insurers from enforcing incentive programs that are "overly burdensome," "highly suspect in the method chosen to promote health or prevent disease," or "a subterfuge for discriminating based on a health factor." And it obliges them to waive outcome requirements for anyone who finds the target weight "unreasonably difficult due to a medical condition."

The more significant challenge comes from the bill's treatment of public health programs. It would introduce "incentives for healthy lifestyles" into Medicare and Medicaid. The incentives, funded by a $15 million annual appropriation to Medicare (for demonstration projects) and a $100 million annual appropriation to Medicaid, would be awarded to beneficiaries and designed "to reduce their risk of avoidable health outcomes that are associated with lifestyle choices, including smoking, exercise, and diet." By law, the incentives wouldn't affect federal benefits. But to change behavior as intended, they'd have to be substantial.

When the government tells insurers what they can or can't do, it's easy to restrict outcome-based incentives. Why let those nasty, greedy companies charge people more for being fat? But the public sector is a different ballgame. When taxpayers fund wellness incentives, they're entitled to see results.

That's why the health reform bill promises to rigorously measure "changes in health risks and outcomes" among Medicare and Medicaid beneficiaries, including "ceasing use of tobacco products," "controlling or lowering their cholesterol," "lowering their blood pressure," and "controlling or reducing their weight." In the case of Medicaid, it restricts incentives to beneficiaries who "demonstrate changes … by meeting specific targets."

So don't expect the government to protect fat people from outcome-based incentives while footing the bill for health care. The more it pays, the more results it will demand.

(Now playing at the Human Nature blog: 1) Debating, clarifying, and rethinking the Polanski case. 2) The beauty of artificial virginity.)

E-MAIL

RECOMMEND... Get Slate RSS Feeds

William Saletan is Slate's national correspondent and author of Bearing Right: How Conservatives Won the Abortion War. Follow him on Twitter here.

Illustration by Mark Alan Stamaty.

COMMENTS

There's plenty of other countries with either non-profit/regulated insurance, or (ultimately) government-funded health care, universal in either case. They get great results (cheaper care, longer lives). Do they discriminate against the fat? Why on earth are we "innovating", doing stuff that nobody else does, when other countries have already tested and proven several different ways of delivering health care?

Assuming that we did embark on such a hare-brained scheme, what I expect would happen is that even "carrot-based" approaches would be channeled into industry-approved (i.e., profitable for someone) directions. So if you spend time at a gym and pay a membership fee, that gets a subsidy. But if you decide instead to walk or bike for small trips, that's informal, not well-measured, and would not qualify. Real world example under the current system, I have tried two treatments for raising "good" cholesterol. Drugs, my tax-advantaged-employer-provided health insurance will subsidize, to the tune of hundreds of dollars per year (turns out drugs don't work well for this). The other, biking for small trips (accumulating at least 50 miles/week, measured with an odometer), is entirely at my cost (but it works).

-- dr2chase
(To reply, click here)

"Second, fat can be avoided or reduced through exercise and healthy eating. If we charge fat people more for health insurance—or charge thin people less, which amounts to the same thing—people will improve their habits."

What bugs me is that this premise is invalid. Fat gain/loss is affected by genetics and hormonal balance as much if not more than eating habits. As such, there are many people who exercise regularly and eat well but are still at what US government charts consider an unhealthy (even morbid) weight.

There has been no study that has proven a significant long term weight loss benefit for "exercise and healthy eating." Yet, this new government plan is harping on that idea. It's hilarious that with one hand, the politicians are decrying "unproven medical techniques" as cost-inducing measures and on the other hand, they're trying to incentivize people to do something that is a sorely unproven technique. I'm sure that "big diet" has some influence here.

Also, it's funny how you never hear discussed that those "additional costs" that fat people supposedly incur include things like ineffective weight loss programs financed by insurance, unnecessary gastric bypass, and even in some cases, gym memberships under the guise of physical therapy. The cost is "healthy eating and exercise" as much as other conditions, and then it doesn't work.

This is prime case of correlation vs. causation. Doctors can't look inside your veins to see if you have plaque buildup from unhealthy habits, but they can look at whether you're fat, so that's what they do, because there are people who are unhealthy and who are fat...never mind the millions of Americans who simply have a natural body weight and distribution that falls outside the norm.

Grr.

-- wontletmeusemyname
(To reply, click here)

What did you think of this article?

Join The Fray: Our Reader Discussion Forum

POST A MESSAGE | READ MESSAGES