31 replies »

1. Hi pcb
   I think all this not so badly, and it is necessary
   to continue to move in this direction!!!

2. Eating habits are SO hard to change. My diet is terrible; I’m a 60 year old single male and I eat mostly fast food or frozen food from the supermarket. I’m not likely to change, I’m just not interested in taking the time to plan menus, shop, & prepare meals. I do have two habits I hope help compensate for this; I work out fairly often and I take supplements. The supplements seem to make a huge difference. I’d always been a bit skeptical until I tried them. Now I’m sold. My favorites come from Jean Carper’s Stop Aging Now site. She’d got a full range of products, including cinnamon and green tea extracts and fish oils. Here the link if you’d like to take a look: http://www.stopagingnow.com . I think it would be worth a visit. Robby Tanner

3. Barry, I bet that a BMI surcharge will be characterized as racism by the black community as I think that sector has a much higher BMI per capita. Won’t fly. Here in NC BC/BS is promoting health prevention through exercise and eating habits. So far no signs of reduced premiums for achieving goals, only minor promotional gifts even though they say employers will get improved productivity. There is no leadership in the insurance industry anyway. If there were we’d have these programs now. The best insurance client is one who has paid premiums for years, gets sick, can’t work, can’t pay premiums, looses insurance or dies before BCNS’s loss ratio gets out of wack. That’s another reason for deductibles and co-pays. And who collects extra $$ for high BMI from all the un/under insured? That’s why a calorie tax to fund positive programs is the only way to go. Stick first, carrot next.

4. Peter,
   I think an insurance surcharge would work fine and would be perfectly transparent. For the 170 million people (including family members) who get their health insurance through an employer, the employer would collect the surcharge through a payroll deduction. For those who purchase insurance, it would be a line item on their bill – standard rate plus smoking surcharge (if applicable) plus obesity surcharge (in applicable). For Medicare beneficiaries, they would also pay the surcharge (if applicable) in the form of higher Part B premiums. We would probably have to exempt the poor on a means tested basis.
   I think a reasonable surcharge would be $30 per month for smoking plus an additional $30 per month for obesity (defined as a BMI of 30 or higher). The smoking surcharge would be the equivalent of a $1.00 per pack tax for a pack a day smoker. The obesity surcharge would approximate 0.2 cent per excess calorie for someone who consumes 500 calories per day more than the amount that would allow maintenance of normal weight. I also do not think either surcharge should be deductible or payable with pretax dollars through a Health Reimbursement Account or Flexible Spending Account. It’s perfectly transparent. It also, I think, strikes a reasonable balance between being enough to get the person’s attention in the hope of inducing him or her to adopt healthier behavior yet not so much as to be harshly punitive. It also focuses the financial penalty on those who are driving excess medical costs through unhealthy behavior while not burdening non-smokers and people with normal or near normal weight.

5. Peter, you clearly missed the point of mt post of paying for preventative care. For example if someone comes to me for physical therapy for low back pain and I show them exercises to strengthen their core abdominal musculature and hips and maintain good flexibilty and instruct them in a cardiovascular exercise program over 12 visits, then they maintain that, let’s do the math. 12 PT visits: $1500. Lumbar spine fusion surgery: $14,000. Another example: the average coronary artery bypass surgery costs $44,000. Which number looks better to you? By preventing illness, we save money by not having to pay for preventable disease. Is it going to prevent all disease? Absolutely not. Will it pay for itself? The numbers above don’t lie.

6. “Politicians all too frequently use general”
   This should have been: “Politicians all too frequently use general revenues to enrichen their friends and play hide the ball with fiscal honesty.”
   I had a minor household emergency to solve and lost my editing position.

7. pcb, yes, yes, and yes again. If it’s got a kitchen then it’s taxed. Subway has the Veggie Delight but it also has the double cheese, extra meatball with sauce. The more loopholes and exceptions you give the larger the tax needs to be and it becomes an administration nightmare.
   Barry, “Ironically, however, if we are successful in reducing the incidence of obesity significantly and people live longer, it may ultimately cost society more in medical costs”, there are those unforseen consequences. I guess we should encourage the worst behavior possible in hopes that dealth will control costs. At this point I disagree about the implementation problems, but not the political problems. I have no illusion about the political strength of the subsidized food industry. But as I said part of the tax would go to enforcement costs which I see as existing local health inspectors and health departments. The reason I like an up front tax at the retail level is it’s visibility. A wholesale tax is hidden from the buyer so its psychological effect is blunted. I believe all taxes should be transparent and many dedicated. Politicians all too frequently use general A retail tax is also easier to use by local communities. As for the use of insurance to stem this obesity tide I don’t believe the industry is capable and I don’t think it will work very well. I believe in a flat rate type all in insurance system that spreads cost and risk over a large pool. If you allow insurance companies to game the system we’ll just have what we have now – risk assessment for profit. The use of cigarette taxes on the other hand has been shown to work.

8. Peter,
   Is Subway taxed in your model? Local sandwich shops or only national chains? Burger joints? Applebees? Jamba Juice? (have you seen the calories on some of those?, -no matter how “organic” the ingredients are-)
   All the food on the menu taxed? Grilled chicken sandwich at Burger King? Size of the item matter?
   Please, give us some details on what makes calories bad and what makes ’em good.
   Barry’s comment on this “probably being an insurmountable challenge” is an understatement.

9. Peter,
   I think you and I are in basic agreement about the fact that incentives matter and that we need to try to find effective ways to encourage healthy behavior and discourage unhealthy behavior.
   Alcohol and tobacco taxes work because there are a very small number of companies that manufacture these products which makes the taxes comparatively easy to collect at the manufacturer level. Taxes on unhealthy food are a different matter. It is probably an insurmountable challenge to design a tax that does the job, can be effectively administered and collected, does not create huge compliance costs for business, and is not perceived as overly intrusive on individuals.
   I think it would be easier to create incentives to combat obesity through the insurance system. Charging the obese (and smokers) higher insurance premiums would be relatively easy to administer, and it would keep the money within the healthcare financing system as opposed to making it available for wasteful earmarks, farm subsidies, defense spending, etc. if we create additional taxes.
   If we move to a health insurance system that incorporates insurance exchanges whereby insurers are required to take all comers but will receive a benchmark rate per person plus or minus an appropriate adjustment for the health risk of the population that each winds up with, sophisticated individual risk scoring using health risk assessments, prescription drug history and claims data will be required. The same information could easily be used to calculate individual insurance premium surcharges based on behavior related risk over which they have control but no other risks including age.
   Ironically, however, if we are successful in reducing the incidence of obesity significantly and people live longer, it may ultimately cost society more in medical costs incurred over a longer life span as well as greater cumulative social security and other benefits. I saw a study in Health Affairs recently that concluded that approximately 50% the lifetime medical costs for an entire population of people born in a particular year occur between age 65 and the end of life. That even takes into account that some modest portion of the population dies before reaching age 65.

10. pcp, I researched Orwell and taxes but could find no reference. I did find a couple of Orwellian references that can be applied to our present regime though: “War is Peace”, “Ignorance is Strenth” and the thought that perpetual war is good.
    In the case of a calorie tax I guess you first have to believe that obesity is a problem, then if you feel it’s worth fighting, come up with a system to do that. I view a calorie tax as just another sin tax. We seem to understand and accept that the use of alcohol and cigarettes add costs to society that need to be paid for. We don’t ask how much you drink or smoke, only that when you do you contribute to the costs involved, whether you are an alcoholic or not. Paying for the cost of alcohol abuse (police, court system, family destruction) is recognizing NOTHING in life is free. Realizing that smoking causes health problems that cost even those who don’t smoke is taking some responsibility for your actions. Why should calorie consumption in an obese society be any different? You ask, “A 920 calorie burrito is “bad.” What if I order 2 500 calorie burritos?” well you would be taxed on 920 calories for the big one and 1000 calories for the two smaller ones. Clearly the government can’t monitor who exercises to offset the burrito any more than it can monitor how much alcohol you consume or how many cigarettes you smoke. I don’t advocate government
    weigh-ins. But when you collect taxes from calorie consumption you have funds that can be used for education and postive programs like tax breaks for people who join and use health clubs. And you have funds that can be used to treat individuals who load the healthcare system with the outcome of their obesity. And that would be my answer to Andrew when he asks, “Why don’t we simply agree to pay for preventative care, whether it’s gym memberships, nutritional consults, etc.”, how are we going to pay for that? From taxes collected for bad behavior we can fund postive programs to fight obesity. I pick fast food because clearly that type of food seems the most destructive and least healthy. But I also advocate transferring the billions of tax dollar$ now used to promote corn production into the production of organic fruits and vegetables to help everyone afford that type of healthy food.

11. Let’s try another track instead of the “tax everything bad” route. Why don’t we simply agree to pay for preventative care, whether it’s gym memberships, nutritional consults, etc. Feel free to insert your idea here. On the flip side, if you don’t take advantage of preventative care that is paid for, should we really be obligated to pick up the cost of that heart disease that was entirely preventable. It’s pretty easy to track people who adhere to preventative principles by tracking visits to a gym, physical therapist, nutritionist, etc. If people have taken steps to prevent disease and still get it (think heart disease here) then that may represent a more justified scenario to have insurance companies, government, whoever pick up the tab. The key issue at the core of this thread seems to be how do we incentivize good behavior and inhibit bad. Does the thought of no one paying for you to have heart surgery since you blew off every opportunity to prevent it make you change your behavior or not?

12. Following this thread, I feel like I’m reading a pitch for an Orwellian Twilight Zone episode
    Calories are bad. I get it. We should tax sugar, vegetable oil, lard, bacon ,sausage, beef, etc. at the grocery store. Heck, rice an beans are pretty high density caloriewise, tax the hell out of them too.
    No? Just “fast food?” What is that? Who gets to define that? Can I get some guacomole on my Chipotle burrito without the govt. getting an additonal take? What if I promise to go for a run in the morning?
    What if I order a small fry? Is that OK? What if I order two small fries? Not OK?
    A 920 calorie burrito is “bad.” What if I order 2 500 calorie burritos? Is that OK? Who is going to decide what is “OK” when I go get some food?
    This is as bad as I’ve seen on this blog.

13. Peter, I’m not trying to sound like an old fogey waxing about the “good old days” (I’m 42, I’m not *that* old!), but my point remains that I think we’re waging “war” on a relatively small part of the problem — the specific foods people are eating. The “war” needs to be waged on two fronts, and I’d argue that the more important front — exercise — is not being waged much at all. So in that sense we have a failure to prioritize.
    As long as we focus on that and not today’s more sedentary lifestyles, the “war on fat” is doomed to fail.
    Having said that, if you are looking more for a way to pay for the added costs of obesity rather than you’re looking for ways to reduce the incidence of obesity, “sin taxes” on fatty and sugary foods could do that in part. But in reality to take this to its logical conclusion — assuming the intention is to tax behavior leading to obesity to pay for their added share of health care costs — you need to tax sedentary behavior, too. Since that’s not feasible without Big Brother monitoring our every move, that’s not feasible. But without that, you’re arguably giving a free ride to people who eat the “right” foods but don’t exercise.

14. Tim, when you and I were kids there was no obesity problem, hence no measures were needed to fight a problem that didn’t exist. The fact is today more people, including children, have sedentary lives and we have an obesity epidemic that (for stuarts interest) is adding unnessessarily to the cost of everyones healthcare and controlling other peoples wealth through premiums or taxes. There has been much discussion about putting gym class back into school. Does recess still exist? I have explained how the calorie tax would work if you re-read the posts. But sure, we can sit around and reminisce about how good the times were in our childhood, but that doesn’t attempt to pay for or solve an unnessary humane behavior problem we have now.
    Stuart, did you read that link to Thomas Jefferson quotes I gave you? He must be high on your list of individual freedom thinkers.:>)

15. How about a tax on your blog postings Peter?
    I’m constantly amazed at the audacity of little twits wanting to control other peoples’ lives and wealth.

16. Andrew is absolutely right, IMO. We seem to be societally focusing on diet in the “war on obesity” and mostly ignore the exercise component.
    One thing we constantly hear about today is how many kids are fat. And all too often, the response is only on the “diet” side of the equation: we have to get rid of anything remotely “junky” in schools, we need junk food pushers to stop advertising to kids, et cetera. And that’s fine and good, but it still misses most of the problem. When I was a kid we ate and ate and ate, regularly having seconds of what was often fatty, sugary food.
    And *none* of us in my family were overweight. We went out and played for hours on end. No one ever had to tell us to go out and play, whether riding bikes or playing basketball on the schoolyard or going to the park playing baseball all day. Society has changed to the point where we use computers and TVs and X-Boxes as “electronic baby sitters,” and some parents don’t want their kids out playing for fear of abduction. The net result is that we have inactive kids, often babysat by electronics and shut-in much of the time…which is a recipe for obesity even with a more moderate diet.
    So really, while diet is a significant contributor to obesity, the increase in sedentary lifestyle is (IMO) even more of a factor. So if we want to go hog wild with the “tax everything for health care” route, why stop at taxing calories, sugar and fat? Why not tax every hour spent in front of the TV or the computer or even at your desk at work, all of which are generally sedentary? Yeah, this is getting a little absurd, but that’s the point. By looking at diet we’re only getting part of the picture, and an active person who consumes 3000 calories a day (and remains fit and at a healthy weight) is taxed more than a couch potato getting pudgy on 2200 calories a day.
    And finally, as for a “fast food tax,” how does that work? Would it be tacked onto the bill as a percentage of the total? Would someone buying a dinner salad with low-fat dressing pay the same tax as someone supersizing a bacon double cheeseburger?

17. Andrew, I advocated the tax on fast/junk food outlets and restaurants not food purchased in grocery stores. I doubt those 3500 cals you consume are from MacDonalds. But if they are then you have an option to not buy the junk food. No tax system is perfect or fair for all, and most tax schemes are political documents produced for special interest. But the tax needs to be broad based, affordable and simple for it to work. If we could tax net calories (intake minus output) then I would be for that, but how is that going to be workable.

18. i like the idea of taxing unhelathy behavior, however a calorie tax is not the right way to do this. I eat upwards of 3500 calories a day because I exercise regularly so that tax is going to hit me pretty hard and I definitely do not fall into the obesity crowd! It seems as a society we only want to focus on the diet component and never on the physical activity component. I actually like the idea of incentivizing good health through lower insurance premiums for not smoking and maintaining normal weight (although BMI is going to through a lot of haelthy physically active people into the overweight/obese categories). I just don’t know how many people would change their habits without a stick to go with the carrot.

19. bev, thanks for the clarification although my wife would disagree that chocolate is NOT an essential food group necessary for sustaining life.
    ” As usual, the few misbehave and the many pay the price.”
    Given the amount of obesity in this country I don’t think it is the few, but the most. I’m not at my ideal weight. As one who never, in the last 15+ years, has purchased from a fast/junk food outlet I would be glad to pay a calorie tax at any restaurant to help pay for obesity costs on our healthcare system. It never helps to be reminded to eat properly. One last point is I would require the tax to be listed separately on the bill so people could see the result of their eating. Hidden taxes are prone to abuse and do not teach anything, if that is your goal.

20. Peter;
    No, no, you misunderstood what I meant. I was saying that humans can survive phsiologically without alcohol or tobacco, so it’s no problem to tax them out of existence. But food (I didn’t specify what kind of food) is necessary for life, so the analogy to an alcohol/cigarette tax is not logical. I certainly didn’t mean junk food or desserts are necessary for life!
    I agree the weigh in idea probably wouldn’t work, although I don’t see why it’s overstepping. One has to provide other physical characteristics for a driver’s license. However, everyone with a BMI over 30 would claim it was genetic and they eat like a bird and they can’t help it, so the shouldn’t pay the surtax. So much for 2 a.m. ideas.
    The calorie tax is interesting, although it would penalize people (I USED to be one of them before I hit 50) who can eat whatever they want and remain skinny with cholesterol of 120. As usual, the few misbehave and the many pay the price.

21. “Give the people what they want.”
    Sex, drugs and rock’n roll.
    “…at least they’ll be able to afford their health insurance!”
    Not if we continue down this path.

22. Give the people what they want. If someone only has to spend $5.38 a day on food (two of these gorditos), at least they’ll be able to afford their health insurance!

23. Peter,
    As one who loves candy, ice cream, soda, etc., I’ve consumed more than my share of all of those over the years, though I’ve learned to moderate my consumption drastically over the last 8 years or so. The source of the vast majority of my sweets consumption: supermarkets. I’ve found that if I don’t bring the stuff into the house, I don’t eat it. If I do, guess what happens?
    I think it is critical to create incentives that will reward healthy behavior and penalize unhealthy behavior. If we can design a food related tax that will do that, fine. If we need to do it through tinkering with insurance premiums, that’s fine too. The bottom line is that incentives matter, and we should incorporate them into either our tax system and/or our health insurance benefit design.
    The other general comment I would make is that I think I am as compassionate as the next person in being willing to pay (through either taxes or health insurance premiums) for other peoples’ bad luck – accidents, bad genes, etc. I am not nearly as willing to pay for their bad behavior over which they have considerable control.

24. bev, first how can you say that the 920 calorie burrito or a high cal. dessert is a necessary food. Food can also be an addiction. If we recognize that obesity is a crisis then by definition a crisis needs action. The beauty of a calorie tax is its simplicity and ease of administration and fairness. I would not impose it on food purchased in grocery stores, at least not unless that became necessary as well if we found that 920 calorie burritos were just being transferred to grocery stores. But I would also remove subsidies on corn production and transfer those to support for organic fresh fruit and vegetables.
    Food companies would have to post the calorie content of the meals on the menu. They know better than us (unfortunately) what’s in their food. People would pay on all calories so that avoidance and loopholes would be avoided and the per calorie charge could be small and bearable. Spot checks could be made to keep the system somewhat honest and done through existing local food inspection departments.
    As usual life is not fair, but doing nothing is also not fair. A tax on aberrant behavior is the most direct way to educate and if you can’t change habits then at least the rest of us would not be totally burdened with the costs. We learned that banning alcohol did not work and banning drugs is also not working, how can you think banning food would work. Calorie tax funds would have to be isolated from general revenues to protect us from politicians bestowing gifts on their friends, and targeted to healthcare costs and programs. Barry, even I don’t want a weigh-in at license renewal, that WOULD be overstepping, and try to get that one past the voters. Even Eric Novack would have to agree that with a calorie tax we would be properly funding a program. See Eric, I agree there should be no free ride.
    As usual the hardest part would be getting this past fast food corporations. But that is why solutions, any solution, has brought this country to a standstill. We can’t solve anything because the money fix is in by special interests who use the shield of free speech to bribe politicians for their own selfish profits and pass the resulting costs on to us.
    Whether it be global warming, war spending over childrens healthcare, or obesity, we are incapable of solving anything until the crisis is so obvious and so costly that it threatens our existance. In the case of global warming I’m afraid we are too little to late and that our children and grandchildren will pay a terrible price. I hope you all have enjoyed the party.

25. Bev,
    You are right that finding a sensible and reasonably equitable way to design, administer and collect a tax on unhealthy food would be a serious challenge to put it mildly. All of the industry lobbying against it would probably make it even more difficult.
    I think it might be easier to attack the problem through the health insurance system, though there will be people who will complain about genetic predispositions, addictions and the like. Then again, nobody ever said life was completely fair. An insurance surcharge for smoking (on top of the high cigarette taxes) would be fine by me. I would also have no problem with a surcharge for a BMI of 30 or higher. Blood pressure can vary quite a bit, especially for people like me who get nervous around medical people. I also know quite a few healthy, athletic people with high cholesterol due to genetic factors. I’m not sure I would want to charge a surcharge to people who have already been diagnosed with diabetes either.
    On the other hand, since I have heart disease, I take a beta blocker, an ACE inhibitor and a statin drug (plus a couple of others). Both BP and cholesterol are well controlled. However, a lot of people with these conditions are non-compliant and stop taking their medication, usually because they feel better or, sometimes, because they can’t afford the copay. The copay issue can be fixed by setting it at zero. The same is true for diabetics. For many, both glucose and HgA1C are well controlled with medication and reasonable diet. I think non-compliance should carry a financial penalty.
    One last alternative is a new insurance product recently rolled out by UnitedHealth Group. It carries a $2,500 deductible (I think) but also offers the opportunity to have up to $2,000 of it waived if the insured either doesn’t smoke or has quit, maintains a normal weight and has well controlled BP and cholesterol levels.
    One way or another, I think we need to incorporate financial carrots and sticks into the equation to mitigate unhealthy life styles and non-compliance with helpful drug regimens.

26. Or how about this additional thought (maybe because it’s 2 am and I can’t sleep) – have everyone applying for a driver’s license be weighed and height measured when they appear for their photo, and their BMI calculated and listed on the license and in their accompanying records. Anyone exceeding a certain BMI would pay a “medical surtax”, with the funds going to the state’s Medicaid program or something. Simpler to punish the consumers of unhealthy food, not the sellers.
    I just mention the license because it’s something virtually everyone must personally appear for at some time, and thus a fairly foolproof entry point for everyone into the governmental record=keeping system.

27. Barry;
    As usual your comments are right on. The only thing that bothers me in your analogy is that alcohol and cigarettes are totally unnecessary for life, whereas food, of course, is. Trying to legislate which foods deserve a tax and which don’t (for instance, you can buy unhealthy foods at the grocery store too) would seem to be a political nightmare. Would it lead to outlawing some outlandishly high-calorie desserts at restaurants, for instance?
    Not to say it wouldn’t be worth trying a fast-food tax; it’s just that i can think of a million ways the industry would exploit the inevitable loopholes in such a law.The bottom line is education (at an early age) and self discipline, traits sorely lacking in our society today.

28. I can’t believe no one has pointed the most obvious thing – how unappetizing that picture looks. Ugh.

29. Peter – I also think the taxation approach is a good idea.
    Perhaps some of the doctors out there can speak to this in more detail, but I’ve read that a very significant portion of our medical problems (and associated medical costs) are related to the following six factors: alcohol, tobacco, obesity, blood pressure, cholesterol, and glucose.
    We already have high taxes on alcohol and tobacco. Perhaps we could design a tax that would be collected at the manufacturer level on fat, sodium, cholesterol, and sugar.
    By the way, I’m a believer in carbon taxes also. I’ve said numerous times that in order to achieve efficient resource allocation, the price of the products and services that we all buy should reflect the full social cost of producing them.

30. A calorie tax sure sounds interesting. But it definitely would be an uphill slog to find a rational way of incentivizing/disincentivizing consumption habits through government action since, as Peter notes, the definitions would be key.
    It seems the various lobbies in the food, grocery and restaurant businesses would have a field day harpooning any legislative efforts to gore their respective oxen.

31. I’ve called before for a health tax on fast/junk food. People have commented that it would be difficult to define. So why don’t we have a calorie tax on food purchased at all restaurants. Maybe like a carbon tax as both are dangerous pollutants.