The Covert Rationing Blog

How to Think About the Obesity Dividend

February 10th, 2008 by DrRich

An article published last week in the Public Library of Science Medicine Journal has created tremendous buzz in the media and the blogosphere. This article compared the lifetime cost of healthcare (beginning at age 20) for obese individuals and for smokers to the lifetime cost for non-smokers who maintained a healthy weight. Naturally, the study concludes that the healthy individuals can expect to live longer than the obese and the smokers (84 years vs. 80 and 77 years, respectively). However, the healthy young people will consume $400,000 in lifetime healthcare costs, vs. only $365,000 for fat people and $321,000 for smokers. Therefore, healthy people, over their lifetime, are a bigger drain on the healthcare system than the obese and the smokers.

The reason this study has attracted so much attention is that it appears to fly in the face of conventional wisdom, which considers it axiomatic that our obesity epidemic is one of the major threats to the stability of our healthcare system. (Interestingly, relatively little of the commentary has had to do with the cost savings the study attributes to smokers. Not only are smokers less expensive to the healthcare system than even the obese, they also die substantially younger - and thus burn through fewer Social Security dollars. When you add to that the stiff tobacco tax smokers pay throughout their entire lives, one might argue that not only are smokers cheaper than healthy people, they may actually constitute a societal profit center. Apparently we have already internalized the inherent benefits to society provided by smokers, however, judging from the relative silence toward this aspect of the study.)

The evil of obesity has become a touchstone. Consider the evidence: All three remaining viable presidential candidates have asserted that it’s the obesity epidemic which is largely responsible for draining our healthcare coffers. (One assumes that the formerly-obese Gov. Huckabee, though less viable as a candidate, agrees with this assertion. DrRich cannot begin to speculate on what Dr. Paul’s obesity platform might look like.) Ms. Clinton, as usual, is perhaps the most straightforward in setting out her feelings on this point of healthcare: According to her website, “About 30% of the rise in health care spending is linked to the doubling of obesity among adults over the past 20 years. Had the prevalence of obesity remained the same today as it was in 1987, we would spend 10 percent less per person - approximately $200 billion - on health care today.”

Even more tellingly, it has become acceptable even in polite circles to openly discriminate against, if not overtly disdain and humiliate, the obese. Fat people are now expected to pay for two seats on airplanes. Mississippi is considering legislation to prevent the obese from eating in restaurants. And in Britain, whose healthcare system has been held up as a model for Americans, doctors themselves are saying that obese patients should be barred from receiving medical services. (Though, in defense of his colleagues, DrRich wishes to point out that these same physician-humanitarians are also calling for the withholding of medical care from the elderly and smokers - so in truth they are not being unusually unfair to the fat.)

So in light of this carefully cultivated scorn for the obese - who are clearly being groomed as a prototype, as a group whose characteristics (ostensibly, their lack of self-discipline, or their sloth, or their selfishness, or whatever other characteristics we can attribute to them that makes them seem different from “us”), justify special treatment in order to serve the overriding good of the whole - in light of this, what are we to do with this new study which says that obesity saves money for the healthcare system? Do we reverse course, and embrace the obesity dividend? Do we encourage supersizing, and, far from refusing to serve them, offer the overweight free second portions? Do we give them deeply discounted heavy-duty suspensions? Better yet, do we give away free Marlboro starter packs to the fat? (Just think how much money we’d save with obese smokers.)

Thankfully, no.

DrRich has pointed out innumerable times the absurdities we find ourselves promoting when the chief purpose of the healthcare system becomes avoiding costs rather than maximizing health, that is, when its chief job is covert rationing. (The Happy Hospitalist has provided us with an enlightening riff on this topic as well.) It is therefore gratifying to say that this is one of those cases where we don’t have to engage in such absurdities. Let’s be plain about it: We don’t need to reevaluate our current vilification of obesity (and smoking) just because people who have these conditions may save us money in the long term.

The reason? We don’t care about the long term.

Who cares that in 60 years, today’s healthy 20-year-olds are going to cost us a lot of money? They’re largely free to the healthcare system for at least several decades. In contrast, the obese and the smokers, what with their chronic diabetes, heart disease, kidney disease, joint replacements, strokes, lung disease, etc., etc., are going to cost us money each year, starting today.

If we actually cared about the long term, we’d be doing something about the Social Security and Medicare entitlements we’ve already signed up for, which in a little more than 20 years will require confiscating more than 50% of each American paycheck, just in payroll deductions. (Never mind income tax.) Heck, just looking at their pay stubs will probably cause most of today’s healthy 20-year-olds to die of apoplexy by the time they’re 40. In any case, the entitlements we’re obligated to provide will threaten societal disintegration long before today’s healthy young adults ever need elder care. Consoling ourselves with the idea of projected long-term savings is like consoling ourselves with the idea of beautiful spring alpine flowers when we’re directly in the path of an onrushing avalanche. Projected long-term savings are completely irrelevant.

The obesity dividend is just smoke, and can be safely ignored. For the greater good of our social welfare, we’re far better off doing what we’re doing today - castigating and humiliating the obese into right actions, and if that fails, then simply following the example provided by one of the civilized healthcare systems we’re encouraged to use as a model, and discriminating against them when they need healthcare. Once we’ve established this useful prototype, we can apply it to whatever additional groups we can identify as targets of our collective indignation.

Whatever it takes to avoid confronting the rationing issue head on.

Posted in General Rationing Issues

8 Responses to “How to Think About the Obesity Dividend”

1. anon wrote on 02/11/08 at 5:55 am :

   The Netherlands study comes from another country with its inherent differences from USA (what they pay for, tax structure, QOL, etc). Also, someone I know who reviewed the study mentioned that it only looked at health, not overall societal costs. Additionally, the legislation proposed to ban serving obese folks is fodder for the press and plain silly (although developments in the UK are concerning).

   Regardless, your points are well taken. My case is careful with this study. Validity here is questionable and I do believe that costs of obesity are real, and trends are concerning. How issues should be handled is another story.

2. DrRich wrote on 02/11/08 at 9:05 am :

   Anon,

   I chose not to address the many problems with the study itself, and for the purposes of this post, to assume its conclusions are accurate. With this assumption, I concentrated instead on what this new “information” might mean to those who are concerned that, under our covert rationing paradigm, we might now need to change our approach to obese people. As you can see, I have concluded that, no, we don’t have to do so. Covert rationing says: It still makes sense to demonize the obese.

   Therefore, it really doesn’t matter, from a practical standpoint, that the study is faulty. Faulty or not, it’s still full speed ahead.

   DrRich

3. anon wrote on 02/11/08 at 12:16 pm :

   Not sure I understand–please augement a bit. If the study is wrong, and the obese do incur more costs, not that I condone the methods, but why would your scenario be correct. Discrimination, villification, demonization, etc., would be against a group who would be utiliziing more assets–both in real time, and long term.

4. Dan wrote on 02/11/08 at 12:41 pm :

   A corollary to this study is my personal observation that headlines frequently trumpet that the death rate from a particular disorder has declined, for which we are all supposed to be grateful. At the same time, no one ever points out that the survivors have to die of something else, eventually.

5. DrRich wrote on 02/11/08 at 2:27 pm :

   Dan,

   Exactly. When the main concern of the healthcare system is saving money, suddenly any good news (such as prolonging survival for some medical condition, or even increasing the proportion of healthy 20-year olds) becomes a threat.

   Now perhaps you could explain the concept of irony to “anon.”

   DrRich

6. anon wrote on 02/11/08 at 3:30 pm :

   dr rich
   i have been following your blog, enjoy it, and was asking a legit question. sometimes posts, as you know, dont encapsulate sentiment well. cant tell if you are flaming me, but if so, oh well. i did not understand your message and wanted you to help me comprehend a bit more. I assure you, i am a pretty capable individual, just wasnt grasping things.

7. DrRich wrote on 02/11/08 at 5:51 pm :

   Anon,

   Sometimes when I think I’m being ironic, I instead wind up being obtuse. I apologize for being obtuse in your case, and hope you will not take offense.

   My point was supposed to be that, in a healthcare system primarily concerned about costs, it appears that it’s OK to treat certain classes of people badly if they cost more money. Following that logic, this study (assuming its conclusions are correct) might make us want to discriminate against the healthy instead (by, for instance, encouraging obesity, which is “cheaper,” by providing the obese with certain benefits). By treating this obviously absurd proposition seriously (and determining by my ostensibly serious “analysis” that we actually don’t have to do this, that we can continue to treat the obese badly and still achieve our goal of minimizing costs), I was attempting to ridicule the current state of our healthcare system with irony.

   And as I re-read this last paragraph, I too can see obtuseness perhaps more clearly than irony. So it’s probably me, not you.

   DrRich

8. anon wrote on 02/11/08 at 7:33 pm :

   thanks for being an understanding gentleman. i will be back for sure.

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