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We all pay for obesity

Catherine Rampell assembles two maps that do a pretty good job explaining why obesity is, whether we like it or not, something the country needs to worry about, as opposed to something that individuals deal with entirely on their own.

First, she posts this image from a recent Center for Disease Control and Prevention report:

obesitymaps.jpg


Then comes this map of Medicare spending rates from the Dartmouth Atlas Project:

medicarespendingmap.jpg

This might also be a good time to repost an old graph showing the percentage rise in health-care costs between 2001 and 2006 for folks in different weight categories:

percentage_rise_in_health_expenditures_between_2001_and_2006_for_people_categorized_as_.png

As long as we help pay for each other through Medicare, Medicaid, and assorted other subsidies, the aggregate health of the nation is a concern for taxpayers, not just individuals. But this isn't just about government. As long as most of us pay health-care premiums based on the average health needs of other people (and that's true for everyone receiving employer-based health coverage, and any other type of risk-pooled coverage), the health of others will be a financial concern for us.

And, er, happy Thanksgiving!

By Ezra Klein  |  November 25, 2009; 1:04 PM ET
 
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Comments

Good to know that a "liberal" like Ezra is enabling our current war on fat people.

Posted by: redscott | November 25, 2009 1:17 PM | Report abuse

So care to tell us why charging obese people more for healthcare because they are a higher risk is a bad idea? Thats one of the huge problems I have with community rating- people should pay more if they make poor choices.

Posted by: spotatl | November 25, 2009 1:19 PM | Report abuse

Look at these maps....obviously more reasons to reconsider the secession of the South.

Obesity, lack of health insurance, high level of bigotry and fundamentalism, why my god why must we be shackled to these people forever?!

Posted by: zeppelin003 | November 25, 2009 1:22 PM | Report abuse

--"As long as we help pay for each other through Medicare, Medicaid, and assorted other subsidies, the aggregate health of the nation is a concern for taxpayers, not just individuals."--

That's the best argument for abolishing Medicare, Medicaid, and assorted other subsidies you've ever made, Klein. Keep up the good work.

Posted by: msoja | November 25, 2009 1:32 PM | Report abuse

Well, I'll leave the question of whether or not obesity is a symptom or a cause (i.e., the real problem is that what gets us fat is what gets us sick) aside for now (tho I'd encourage you to check out Gary Taubes here: http://www.dhslides.org/mgr/mgr060509f/f.htm -- we can't solve the obesity problem because our hypothesis is flawed).

For now, I just want to comment that, to me, these two graphics seem to be examples of correlation, not causation. States like California, Connecticut, Massachusetts, New Hampshire, South Dakota, Arizona, Colorado and even Texas stand out for not being particularly illustrative of the point you're making.

As Atul Gawande made very clear, there's a lot more going on wrt reimbursements per enrollee!

Posted by: bowseat93 | November 25, 2009 1:46 PM | Report abuse

The obesity map might be more useful if it didn't depict certain inland waterways in the same color as more than 30% obesity. For example both Puget Sound and the San Francisco Bay/Delta show up as jet black which for people not acquainted with the geography of either looks like there is a big pocket of obesity where if fact the only fat creatures are salmon and orcas.

There are similar effects in the Columbia and Mississippi rivers and along the shores of states like the mid-Atlantic and the Gulf Coast and Alaska that have barrier islands and intercoastal waterways.

Plus the shade of gray that marks most of Alabama, Mississippi and eastern Oklahoma doesn't seem to be represented in the color table (at least as it renders in Safari) and is totally absent in the western US. So I don't find that map very useful.

Nor is the reimbursement map readily interpretable. If we look at the darkest color it seems to be a blend of high cost urban areas where the reimbursement is not necessarily related to health outcomes as much as office rents (S.F, LA, NYC, Chicago, Boston) along with some areas more readily associated with high health care utilization (west, east and south Texas, north Lousiana).

Frankly I don't see that these maps are particularly useful individually and are maybe less than useless in combination. Because not only is correlation not causation, here it is unclear is correlation is even correlation.

Posted by: BruceWebb | November 25, 2009 1:49 PM | Report abuse

Ah, I feel better. I just checked out Catherine Rampell's original post. She's getting pretty dinged there, e.g., "Useless comparison. You’re making a mess of the statistics." Ouch!

Posted by: bowseat93 | November 25, 2009 1:51 PM | Report abuse

As long as we help pay for each other through Medicare, Medicaid, and assorted other subsidies, the aggregate health of the nation is a concern for taxpayers, not just individuals.
*******

precisely, which is why tea partiers are on the money when they point out that health care reform will shrink spheres of autonomy.

this is about liberty people

Posted by: dummypants | November 25, 2009 1:52 PM | Report abuse

We could have a health-care system that covered everybody at lower cost than the current system and that didn't encourage Ezra's beggar-your-neighbor strategy of saying that we're going to impose significantly higher costs on you because we find your choices morally blameworthy. But then we'd have to admit that the private market has failed and either strictly regulate it like the Swiss do or go to a single-payer model like the other major industrialized countries do. Then the costs would be significantly reduced and we wouldn't be forced to scramble for savings and penalize people for choices, status, or behavior that "we" don't like. So, once again, thanks, Ezra, for acceding to the private market model and the exciting blaming games that we can continue to engage in against the "undeserving" (however defined).

Posted by: redscott | November 25, 2009 1:53 PM | Report abuse

What about smokers? There has been a curious lack of condemnation of smoking since Obama took office. It's a known health risk.

Posted by: truck1 | November 25, 2009 1:57 PM | Report abuse

Hear hear, zeppelin. I agree 100%. Why must we keep subsidizing those people for literally every little thing?

Posted by: luko | November 25, 2009 1:58 PM | Report abuse

"Catherine Rampell assembles two maps that do a pretty good job explaining why obesity is, whether we like it or not, something the country needs to worry about, as opposed to something that individuals deal with entirely on their own.

Ezra,

You've misunderstood her post. She was showing that there was LITTLE overlap between the two maps, thereby calling into question the relationship between obesity rates and health care cost growth.

Of course, she's restricted to Medicare data on the cost side from Dartmouth, which when analyzing something like the impact of obesity, is a major flaw.

Your other graph is a good one, but is contrary evidence to HER post and maps. That said, this is just another reason why not having financial incentives on health care consumption is a gaping hole in the current reform plan. I'm well aware of the socioeconomic connection to obesity, but that doesn't mean we shouldn't make it worth it for people to be financially aligned on preventing obesity. Folks upstream are calling for rating differentials on something presumably like BMI. Whether its that, or an annual insurance credit, either work for me. But we need something. Along with a heavy dose of food policy improvements, which incidentally would save more money than anything on the table this time around for reform. To Ezra's credit he knows that-- so he's given us a brutal dose of food posts the day before Thanksgiving.

Thanks Ezra. :)

Posted by: wisewon | November 25, 2009 2:06 PM | Report abuse

This post was a parody, wasn't it?

Posted by: ostap666 | November 25, 2009 2:08 PM | Report abuse

Given the size of the people at typical tea parties and Palin book signings (check the interviews with her fans at Daily Kos), the most helpful thing she could have done was to do a diet and workout book.

Seriously, I suspect an inverse correlation between obesity and general life satisfaction, and a direct correlation between anger/stress levels and obesity. It fits both blacks and whites in the South (highest obesity rates) for different reasons, in that real or perceived victimhood are probably equally stressful and angering.

So perhaps we should focus more attention on how to reduce the stress of everyday life and start making life easier for people who aren't thin and rich.

Ratcheting down the fearmongering by fiat is counter to the First Amendment. At a personal level, less computer time and more exercise and outdoor activities would seem to be in order.

Posted by: Mimikatz | November 25, 2009 2:10 PM | Report abuse


Our family spent several years with a health insurance policy bought on the individual market (very costly). When I saw the rate tables used, it provided a huge motivation for DH and I to shed some pounds. We did (it took two years), and it lowered our cholesterol and our premiums. It's made me a firm believer in using positive reinforcement to provide lower premiums to those with lower risks (within individual control). Smokers and the obese should pay for the higher costs associated with their healthcare (which would cover things like special huge wheelchairs, patient lifts, oversized gurnies, etc). Why the heck should we be asked to pay for bariatric surgery?

I'd extend these higher premiums to Medicare, but I'm cynical enough to know that it will never happen in my lifetime.

Posted by: Beagle1 | November 25, 2009 2:28 PM | Report abuse

Good to know that a "liberal" like Ezra is enabling our current war on fat people.

Posted by: redscott | November 25, 2009 1:17 PM | Report abuse

redscott,

If you'd rather the obese stay obese and die that's fine. The rest of us would like to not only help their wasitline but also the country's bottom line considering all studies show that 70-75% of healthcare costs are related to obesity, heart disease, diabetes and cancer. Now cancer has a very weak link but the other three are absolutely linked together.


Mimikatz,

I'm sorry but obesity is an equal opportunity killer. Its just as likely to kill a tea party person as it is a progressive person.

I do agree with your point about all of us sitting behind a computer. Kids problems with obesity can be centered around video games too but again not everyone.

And Ezra thanks again for getting back to this truth about healthcare costs that gets very little "play" at all in liberal circles. No one wants to blame themselves when its much easier to blame a pharmaceutical company or an evil insurance company executive. I still remember back to the days when i was in high school and a goofy actor was the chairman of the President's council on Fitness back in the late 80's and early 90's. What's he doing now??

Posted by: visionbrkr | November 25, 2009 2:32 PM | Report abuse

visionbrkr,

if youd rather have the government ration your food as well as your health care thats fine. id rather eat whatever i damn please and pay the higher premiums that come from risk profile than have the government micromanaging my life and justify it by the existence of community rating.

this entire discussion is absurd and it shows how democrats who have learned the hard way the perils of openly pushing a socialist and/or nanny state agenda have artfully find a way to push that agenda by stealth, cloaked in "systems" of risk spreading and "collective responsibility".

sane americans are willing to be exposed to a marginally higher degree of risk for in exchange for the right to live as adults making our own choices.

Posted by: dummypants | November 25, 2009 2:50 PM | Report abuse

Perhaps the government hands off my food types would be satisfied if the feds stopped subsidizing corn and the associated agri-business products. In that case, we could all be happy, because meat and processed food would be accurately priced to give people an incentive for better food choices.

On a separate note, those maps are more remarkable in that it really makes you wonder what is going on in CA and TX.

Posted by: elainelinc | November 25, 2009 3:06 PM | Report abuse

How much do we save on social security because fatties die earlier?

Posted by: MrDo64 | November 25, 2009 3:07 PM | Report abuse

dummypants,

I'm sorry but if I'm paying for it (more taxes), i want to make sure you're not fat and costing ME money.

community rating is all about risk spreading which I'm all in favor of. I'll pay more when I'm younger (than I'd actually owe) so that I pay less when I'm older. You can't have your cake and eat it too and still remain somewhat healthy.

Posted by: visionbrkr | November 25, 2009 3:58 PM | Report abuse

You're not paying for it, any more than you are paying for David Axelrod to get new granite countertops in his summer palace. All money given in taxes is fungible. It is not your business if someone else is fat. period. This whole way of thinking, relentlessly promoted by the administration and Mr. Klein, as one of their spokesmen, is collectivist. Designed to turn citizens against each other, to pit them one against the other, to make them focus on the idea that they are paying for the lifestyle of their neighbors. The goal is to atomize the population. To judge by what you said (I want to make sure you're not fat) it's working!

Posted by: truck1 | November 25, 2009 4:42 PM | Report abuse

I wonder how much of the increased cost for obese people has to do with the massive increase in bariatric surgery in recent years? I can't (quickly) find a statistic for the years in question, but between 1998 and 2002, the number of bariatric surgeries performed increased by 450%, from about 12,000 to about 70,000 per year. When you consider that those surgeries average from $18,000 to $35,000, that's a lot of costs. It would be interesting to see that separated from the other medical costs.

Posted by: julie18 | November 25, 2009 7:51 PM | Report abuse

How much do we save on social security because fatties die earlier?


Posted by: MrDo64 | November 25, 2009 3:07 PM | Report abuse

How much do we save on health care because they die younger? Smokers too.

Making this a financial issue is a mistake--it's not at all clear that we spend more on the obese than on normal weight people, and that's due to the fact that obese people die younger.

Posted by: amalg | November 26, 2009 1:50 AM | Report abuse

"How much do we save on health care because they die younger? Smokers too.

Making this a financial issue is a mistake--it's not at all clear that we spend more on the obese than on normal weight people, and that's due to the fact that obese people die younger.

Posted by: amalg | November 26, 2009 1:50 AM"

Obese people and smokers may die prematurely, but we spend way more on them before they die. They have so many more health issues along the way. It's a bit like how death row doesn't wind up saving the state any money compared to life imprisonment, what with all the appeals and extra incarceration issues and everything.

Posted by: simpleton1 | November 26, 2009 9:49 AM | Report abuse

Responding in part to elainelinc's query about Texas and California. California's obesity rates aren't highest in car-crazy Los Angeles and Orange Counties, nor in the food-obsessed Bay Area, but in "farm country" -- the Central Valley -- especially the lower San Joaquin Valley. There are a few reasons why this is the case: a high incidence of poverty (running a farm and working on a farm don't pay well), land-use policies that encourage sprawl and discourage walking, a dominance of processed food options. This piece in the Fresno Bee tells the story of the Central Valley: http://www.fresnobee.com/local/story/1559656.html

I suspect that coastal California's low obesity rate is due to the higher average incomes found in those regions.

And, as BruceWebb pointed out, the big black area on the central coast of California is San Francisco and San Pablo Bays, not a bubble of obesity.

Posted by: meander510 | November 26, 2009 12:25 PM | Report abuse

For all those who want to "make sure" that someone else's fat isn't costing them more money, there are some not so simple solutions. The simplest is recognizing that it is rare, percentage-wise, for obesity to be a "choice." Obesity has a higher incidence among low income people, not because they eat more but because the food they have access to is unhealthy. Poor urban neighborhoods ("ghettos") disproportionately do not have supermarkets within walking distance, and are also disproportionately populated by people who can't afford to own cars. Add to that the paucity of public transportation in some places (I live in one), and you get people who are living on McDonalds (which does settle itself in poor urban neighborhoods). It's cheap, it's accessible, and it's what they got. It sustains life but yes, in excess it causes obesity and associated health problems (remember Supersize me?) Some of the people in these communities would like to buy healthy food, they just don't have access to it.
So yes, obesity is a problem. But, Ezra, you've left out the ways in which it's a systemic problem, not a personal one. Some solutions: more public transportation. some sort of real plan for the revitalization (not gentrification) of inner cities. Cooperation between communities, food pantries and farmers markets (this has started to happen in some places-when I lived in Philly, the local farmer's market had started to take food stamps, and as a result people in surrounding neighborhoods were eating healthier). Working class jobs that pay living wages. The solution particularly to the issue of obesity is less medical than one might think.
(I also think it's interesting that obesity-which is more prevalent among lower income folks-becomes a matter of "choice" in people's rhetoric, while the same is not true of diseases that attack upper income levels. Anybody stopped to think about the levels of gastro-intestinal issues, ulcers, high blood pressure, anxiety etc, that occur in upper middle class communities, particularly people who work high stress upper level jobs? Those could also be conceived of as a result of "choice"-for some reason that doesn't happen often, though.)

Posted by: chanakf | November 26, 2009 12:51 PM | Report abuse

To follow up chanakf's great points, I just came across this from The Obesity Society in the Washington Times:

http://www.washingtontimes.com/news/2009/aug/16/solutions-eradicating-americas-obesity-epidemic/

Lots of good points there, including the need for research dollars that better match the magnitude of the challenge.

Posted by: bowseat93 | November 26, 2009 7:18 PM | Report abuse

amalg,

when they die is not what costs more or less, its what they live through and how long they live through it. Think of it this way a healthy vegeterian dies at age 90 of natural causes as compared to a obese diatetic dying of heart disease who had several quadruple bypass surgeries. Who do YOU think costs the systems more?

And I agree partially with the idea of inner cities and the lack of food choices there but the McDonald's excuse is crap. Salads are on the dollar menu there too. I believe its psychological as well too. When and if living wages were increased how can we ensure that the monies that are redistributed to those populations go towards healthy eating to combat obesity and not unnecessary items such as IPOD's, cellphones etc.

Posted by: visionbrkr | November 27, 2009 9:25 AM | Report abuse

Back in the 80's Saddam decided that most of his generals were too fat. He ordered them to lose sixty pounds each. The "program" was a success, and most lost the weight.

Posted by: truck1 | November 27, 2009 2:03 PM | Report abuse

"precisely, which is why tea partiers are on the money when they point out that health care reform will shrink spheres of autonomy.

this is about liberty people"

Especially the autonomy of those who are enrolled in Medicare or covered by private employer-subsidized insurance? Which is almost all of them? Very few uninsured people protest health care reform. Those that are covered are already paying for other people's unhealthy habits through their premiums, and they have no other choice. That's how the system works. To claim that reform will reduce the liberty of these people is nonsense. If you reject the insurance principle outright and believe in everybody paying out of pocket for whatever cost they cause, you should be consistent and oppose the current insurance system. Opposing reform and protecting the status quo in the name of autonomy is dishonest and unprincipled - in a word, it's precisely what conservatives would do.

Posted by: carbonneutral | November 30, 2009 12:38 PM | Report abuse

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