Update 12/30: I corrected some inaccuracies in the original version.
Updated12/30, part 2: Over at Slog, Erica Barnett politely takes issue with this post and has some smart ideas to improve the plan. My reply is below the jump.
Seeing as how this year’s holiday overeating falls on the eve of a national health care debate, I give you an interesting idea from the land of all things deep-fried:
…the Alabama State Employees’ Insurance Board approved a plan that will charge workers an additional $25 to cover their insurance premiums, if they don’t take advantage of free health screenings available to all state employees. The program, to begin in January, will require state workers to receive medical screenings for body mass index and health problems such as high blood pressure, high cholesterol and obesity.
Alabam’s program is unfairly being called a “fat tax” but that’s an inaccurate description. In fact, the $25 fee is optional—at least at first.
Find this article interesting? Support more research like this with a gift!
The confusion is probably not helped by the strange and convoluted descriptions that abound. (Here’s the clearest, and here’s the most comprehensive, that I could find.)
So here’s how it works. Let’s say you’re a state employee and you decide to get the free health screening in order to avoid the fee. One of two things will happen: either 1) you’re deemed healthy and you don’t pay the fee; or 2) you’re deemed unhealthy and you’re offered a free consultation with a doctor. If you fall into that second category, you have a further choice. You can attend the free doctor’s visit, in which case you don’t pay the fee. Or you can skip the free doctor’s visit, in which case you’re looking at $25 per month extra in insurance premiums.
That’s it. At first, you avoid the fee just just by talking to a doctor. You don’t have to do or pay anything further, and you don’t have to drop 40 pounds right away. Of course, given better medical information some unhealthy employees may want to do something. But that’s sort of the point.
Where Alabama’s plan becomes “tax-like” is for obese folks who don’t show progress. A person determined to be very obese in 2009 would have until 2011 to demonstrate progress. If not, he or she would face the $25 higher premiums. Apparently, the insurance board has not yet determined what will qualify as sufficient progress to waive the fee. What is clear, at least according to this MSNBC article, is that the threshold for having to consult a doctor, and subsequently show progress, is at a Body Mass Index of 35 or higher. (For reference, that would be for a 5’6″ person weighing 217 pounds or more, or a 6’0″ person weighing at least 258 pounds.)
Given the serious health consequences of obesity and its related ailments—not to mention the high cost of treatment—it’s hard for me to see how this isn’t a good idea. A few simple exams, access to good information, and the opportunity to make a change. What’s not to like?
H/t to Ketty Loeb for the idea.Photo is of a KFC “Famous Bowl,” an image that never fails to ruin the commercial breaks for me during Seahawks games.
So. Now to the friendly debate with Erica. Here’s her take:
Tara Parker-Pope—no radical fat activist herself—wrote earlier this year that “there is growing evidence that our obsession about weight as a primary measure of health may be misguided.”
Last week a report in The Archives of Internal Medicine compared weight and cardiovascular risk factors among a representative sample of more than 5,400 adults. The data suggest that half of overweight people and one-third of obese people are “metabolically healthy.” That means that despite their excess pounds, many overweight and obese adults have healthy levels of “good” cholesterol, blood pressure, blood glucose and other risks for heart disease.
At the same time, about one out of four slim people—those who fall into the “healthy” weight range—actually have at least two cardiovascular risk factors typically associated with obesity, the study showed.
So if obesity isn’t the best predictor of health and mortality, what is? Overall fitness—which, interestingly, does not correspond directly with BMI. And fitness is determined almost as easily as BMI is—by having a person perform a treadmill test. Research has shown that fat people who perform well on treadmill tests are at much lower risk for health problems than skinny people who are out of shape. (A treadmill test could also help get around another potential problem with the Alabama proposal—the fact that, besides the obese, the only people who will pay a premium for health insurance are smokers. It’s easy to lie about whether you smoke; it’s harder to lie about how long you can run).
Back to Parker-Pope:
Those with the lowest level of fitness, as measured on treadmill tests, were four times as likely to die during the 12-year study than those with the highest level of fitness. Even those who had just a minimal level of fitness had half the risk of dying compared with those who were least fit.
The results were adjusted to control for age, smoking and underlying heart problems and still showed that fitness, not weight, was most important in predicting mortality risk.
Now, in general, are you more likely to be unhealthy if you’re morbidly obese? Sure. But if there’s a more accurate way of measuring risk—one that acknowledges the fact that it’s possible to be overweight and healthy—why not use it?
And to that I say: sure. Fine. I (mostly) agree.
But first, a quibble. Evaluating BMI is much easier than conducting a treadmill test: it takes about 30 seconds. It may simply be impractical to spend the time to have every state employee put on a treadmill. That said, if a treadmill test is a better predictor of health outcomes than BMI, then we should probably use that instead, at least for those we have some initial reason to be concerned about—i.e. those who are very obese.
And to be fair to the Alabama program, the state will not be targeting everyone who falls into the “obese” category as determined by BMI (i.e. above a BMI of 30), only those who are very obese (i.e. above 35). I don’t know the underlying research here, but it seems possible, even likely, that having a BMI above 35 is not nearly as poor a predictor of health outcomes as a BMI above 30 may be.
So here’s way that the Alabama program could work. Those with a BMI above 35 could be required to demonstrate fitness on a treadmill test rather than actually lose weight. That wo
that the only folks who pay the higher premiums are those who are both very obese and also exhibit poor fitness—surely a risky category for individuals, not to mention costly to insurers.
Okay, now what’s not to like?
Is there some legal reason that you can’t give people a cash bonus for getting their annual physical? The effect is the same, but setting it up as a penalty for non-compliers is a very odd marketing decision. Maybe they’re just generally falling down on the PR front – they don’t seem to be getting a consistent message across to the media. The WebMD article you linked claims, contra CNN, that employees will actually be stuck with the higher premium if they don’t improve their health (or lose weight) within a year.Anyway, I don’t think it’s unfair to call this a “tax” – even if it’s just one doctor visit, people’s time has value. It’s a little tax, not a big one, but for people who are objecting it on principle that might not matter.
Eric de Place
Maria, I went back and made some corrections based on further research. Nice catch.
Matt the Engineer
I think even if this is a “fat tax”, it’s a good idea. I’d like to see what effect this has over the long term.
Instead of calling it a fat tax it should be called the lazy tax. Its used to force people to get a health screening, which goes against our civil rights. Even though its a good idea if someones wants to be fat let them. The other can join me on my site to help them lose some weight http://www.manboobssolutions.com
It may or may not be good idea to penalize people for poor health choices (and it’s probably a better idea to reward people who make good choices). But it’s a bad idea to let such ideas be stigmatized by labels like “fat tax.”Remember what happened to the Center for Science in the Public Interest when they sent out a few new releases about the fat content of some popular, fast food choices? The food industry struck back by saying that CSPI was trying to be “the food police.” See
apologies for the earlier, garbled postIt may or may not be good idea to penalize people for poor health choices (it’s probably a better idea to reward people who make good choices). But it’s a bad idea to let such ideas be stigmatized by labels like “fat tax.”Remember what happened to the Center for Science in the Public Interest when they sent out a few new releases about the fat content of some popular, fast food choices? The food industry struck back by saying that CSPI was trying to be “the food police.” See this article in the NY Times. That label, with its overtones over negativity and coercion, was dishonest and unfair, but it put CSPI on the defensive, and if I recall correctly, they had to scale back some of their efforts (although you wouldn’t know that by looking at some of the current materials at the CSPI site). But as George Lakoff and the gang that invented “the death tax” could tell you, giving something you don’t like a bad name is half the battle.
Erica C. Barnett
Eric, I’m just not convinced that putting people on a treadmill is that difficult. Treadmill tests are typically conducted for only 5-8 minutes… which isn’t that much longer than it takes to calculate BMI or do a caliper test. Unless you’re testing everyone, then you either must 1) discriminate based on how heavy a person is, or 2) ask a long series of tedious questions and/or do a bunch of invasive tests to determine which people you “have some initial reason to be concerned about.” Because there are plenty of things (lifestyle choices, cholesterol levels, etc.) that warrant concern beyond BMI.
I don’t see a problem with forcing people to confront their obesity and un-healthiness. I do see a problem with using insurance premiums to do so. Giving up control to insurance companies or using them to control things is a *bad thing*.
Get Rid of Man Boobs
I do agree that it would be better to reward people who do the right thing instead of penalizing them for not. The company I work for gives incentives for improving your health, such as reimbursing you for a gym membership or if you buy some work out equipment.
I see a vein of judgement running through the comments here. It seems like a good program in Alabama to me, but statments like “determined to be very obese” tells me that you and several of the commenters here have no clue about the reality of genetics, insulin, the pancreas, allergies, etc. in weight issues.Read around some and you will find that some people can eat candy and Taco Bell all day and never get fat (though they may have a high percentage body fat and be unhealthy) and others can get fat eating meat, beans, beans and drinking milk (and have a high BMI and yet be perfectly healthy).I am not fat, but obesity runs in my family and I have seen very clearly that there is a lot of societal judgement and just plain ignorance about the causes of obesity and virtual total ignorance about the difficulty of losing weight and keeping it off keeping it off, especially for people who have insulin reistance in their families.The jury is still out on what makes some folks fat, but what is sure is that once someone is fat it is very difficult to get thin again and in most cases it is not a case of “lazy”. It has to do with metabolics and body chemisty. The body works like this: the fatter you get, the more fat it stores and the more it resists losing fat.If calories were all that mattered the prisoners in concentration camps would have died within a few months, but they managed to hang on for years with only 600 or so calories a day. Why is that? Because their body slowed their metabolisms. With all of our crappy food and sugary foods we eat these days, and especially our grain-heavy diet, many peoples’ metabolisms are doing the same thing, only they are not thin.Once you are fat it is extremely difficult to get it off and keep it off…I can assure you from cases I have seen that it has nothing to do with lazy or even continuing to eat poorly.
To those of you who say that it is a choice and that people are fat because of what they eat, it’s NOT ALWAYS TRUE.I have Cushings disease, fibromyalgia, and degenerative disc disease with slipped vertebrae (not slipped disc). Cushings directly causes lots of weight gain due to a tumor on the pituitary which puts out too much cortisol. The surgery to remove the tumor does not cure the disease – just like with cancer, it can grow back – and most of us cannot lose the weight no matter how correctly we eat. Coupled with the Cushings, my fibromyalgia and spinal disc disease causes such great pain that exercise other than walking or light water exercise is impossible. Even so, due to hard work and diligence, I have “only” gained 50 pounds in the last ten years instead of ballooning into morbidly obese. Cushings also causes high cholesterol and high blood pressure.I had to stop teaching school and go on disability.I guess if I had taught school in Alabama instead of where I am, I would be “penalized” for being fat.
I don’t think a fat tax is very practical – there are several things wrong with Pigouvian taxes in general. They are hard to calculate because it is impossible to determine the exact amount of externality caused, in this case by obesity, and they affect different people in different ways! Here is an article about why a fat tax wouldn’t work: http://www.mindreign.com/en/mindshare/Global-Economics/Fat-Tax/sl35291137bp387cpp10pn1.html