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An Obamacare Fine on Overweight Americans: Discriminatory and Ineffective

Amid the rancorous debates over the Affordable Care Act, one provision deserves to be getting serious discussion.

It’s a provision that allows employers to increase the amount that they may fine their employees for “lifestyle” conditions, such as being overweight or having high blood pressure or high cholesterol.

Almost 37% of Americans are overweight or obese. The supposed goal is to use financial penalties to reduce obesity, the health costs of which exceed $200 billion per year. But this idea, while well intended, will not help Americans suffering from obesity, a medically defined disease and disability. In fact, it will likely make their situation worse.

For years, the country’s “wellness” industry has offered health-enhancement and obesity-reduction programs to corporations, from gym memberships to dietary counseling. For obesity, this approach has not worked. Research on these programs shows that they have not significantly reduced weight or cholesterol levels, or improved any other health outcomes.

Even the most successful programs, such as Weight Watchers, achieve an average two-year weight loss of only about 3% for their members— and even that tiny weight loss often returns later.

The failure of such programs arises from the complexity of our obesity epidemic. For one thing, some people have a genetic predisposition to obesity. If you are unlucky enough to have certain genes, you are up to 12 times more likely to be clinically obese – something that will be difficult to correct, even with a good diet and exercise.

Much obesity starts in childhood, when environmental factors cause children to drink too much soda, consume high calorie foods, and watch too much TV.  By the time these kids become adults, they suffer from both obesity and diabetes – conditions that are almost impossible to reverse. In short, once you are obese it is extremely difficult to lose enough weight, even with financial penalties as an incentive.

These problems will only become worse under the Affordable Care Act. Under the Act, starting this year companies are  allowed to increase the surcharges to employees with medical conditions to 30 percent of their health insurance premiums for an average charge of about $1620 per year.

(Prior to 2014,  companies could assess a 20% surcharge.)

This is cause for serious concern. Not only does the change lend credence to a discredited approach to fighting obesity, but it in effect allows companies to punish their employees for pre-existing conditions, something that Obamacare was designed to avoid.

Worse that being simply ineffective, financial penalties for obesity have significant negative effects. They erode trust between employers and employees, prompting some workers to quit or suffer the genuine fear that the release of private health data will endanger their future employability.

These penalties also discriminate against the poor — many of whom live in neighborhoods with limited access to nutritional foods but plenty of cheap junk food available – and against people with mobility problems who are more likely to be obese. Large controlled studies show that increasing health care charges actually steers people away from essential medical care, exacerbating high blood pressure, worsening vision, and increasing mortality by 10% among low income people with chronic diseases.

Large increases in insurance premiums- up to $5000 for a family of four- also result in uninsurance or switches to cheap but stingy high deductible insurance plans (with very high up-front payments of up to $12,000 before medical care is covered). Our research shows that such plans have been linked to reductions in life-saving care, including colorectal cancer screening, ER visits, and diabetes medicines. The new surcharge will only make this worse.

There is no magic bullet for solving the costly epidemic of obesity, but fining those who suffer from the condition is unethical, disrespectful, and counterproductive. It is likely a violation of federal laws to discriminate against employees based on obesity (a disability) or genetic make-up.  Yet that is what this ill-conceived ACA penalty allows.

The Equal Employment Opportunity Commission (EEOC) and other legal advocates for those with pre-existing conditions should seek a reversal of these discriminatory penalties in the courts. In the meantime, the EEOC needs to issue guidelines with strong nondiscrimination protections for employees in “wellness programs”—as they have been called upon to do for some time now.

Rather than penalize individuals, we need to emphasize population-based obesity prevention, such as using financial incentives to increase healthy food access in low-income neighborhoods. We should increase budgets for physical education in schools, not reduce them; raise taxes on soda and other high calorie beverages, and institute proven programs that limit sedentary TV and screen time.

And among those who are already obese, offer respectful long-term behavioral programs that reduce a few realistic pounds at a time, rather than fining those who fail to achieve what are nearly impossible goals.

Stephen Soumerai is Professor of Population Medicine and Director of the Drug Policy Research Group at Harvard Medical School and Harvard Pilgrim Health Care Institute.

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RespectedCriminal4beautemer skincareweight Loss surgery cost in Californiacollar lights multi functionGreat Lakes Biodiesel Inc. Recent comment authors
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RespectedCriminal4
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RespectedCriminal4

I Agree with all that was said it was very sound and researched. Until you get to the part of restricting people and how they operate by raising prices on certain items and controlling television even more than it already is. Look life will always be life,untamed, wild and ever changing just like people. The way we go about life in our own way raises its balance and discourse naturally. Adding another government like situation penalizing the mass while helping the few is not what we need. Isn’t that exactly why you wrote this paper? And a question for you… Read more »

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Brad
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Brad

I think this article is just another example of the growing entitlement views in our country. Though I think the tax incentive may at least cause more tax paying Americans to be aware of the problem, increasing premiums for the obese should be looked at primarily as an incentive program. That’s just something that may or may not come along with it. This idea is first and foremost about taking responsibility for one’s own actions. Obesity is indirectly a cause for so many healthh problemst hats it’s simply not fair to have others subsidize the cost of a lifestyle decision.… Read more »

vesta44
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vesta44

Brad – I started out my adult life at the height of 5′ 9″ and 175 lbs (well within the “normal” BMI). I got pregnant and gained 60 lbs. I got back down to my starting weight when I got hit by a car and spent two weeks in the hospital and 6 weeks in a nursing home (I had a fractured pelvis and broken leg, and couldn’t walk AT ALL for the first 6 weeks after the accident). I got pregnant again, and in spite of not being able to eat because of 8 months of morning sickness, my… Read more »

Lawrence
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Lawrence

Make positive changes to these these factors and everyone wins (except for the medical industry and drug manufacturers) The billions saved on medical care for diseases and medical conditions caused by poor lifestyle choices, could be used to feed, house, and educate millions of Americans, and to build a stronger society. More than one-third of U.S. adults (34.9%) are obese. [Read abstract Journal of American Medicine (JAMA)] An estimated 42.1 million people, or 18.1% of all adults (aged 18 years or older), in the United States smoke cigarettes.1 “Drug use is on the rise in this country and 23.5 million… Read more »

Lawrence
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Lawrence

So Peter1, you consider your cheap swipe to be an insightful reply? Do you really think that people who abuse their health should have other people pay for the unnecessary medical costs that they cause? We wouldn’t have a healthcare crisis if people (perhaps, like you) didn’t choose to abuse alcohol and drugs, eat to much fattening food, or smoke. It’s people like you who think that they can do whatever they want, then leave the bill for other people to pay for the poor choices that they make. You don’t need to lead a “pristine”, or “Puritan” life, just… Read more »

Peter1
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Peter1

Lawrence, define “abuse” and “eat too much”. Again, tell us your cultural consumption habits so we might judge your risk to US.

“It’s people like you who think that they can do whatever they want, then leave the bill for other people to pay for the poor choices that they make.”

And who am I, in the “people like you”?

Lawrence
Guest
Lawrence

After being lied to by the President of the United States about being able to keep our medial plans, why are people who live healthy and responsible lives having to pay as much for insurance as people who are obese, smoke, take drugs, have risky sex, or have a combination of any of these risk factors? All of the vices mentioned above are personal choices that create health problems, needlessly costing us billions of dollars every year to treat, but the only people being punished for them are the healthy people who must pay more to subsidize the medical costs… Read more »

Al Lewis
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Al Lewis

smoking and taking drugs and driving recklessly are indeed choices and people do/should pay more for them.

And I’ll agree with you that obesity is a “lifestyle choice” as soon as Oprah Winfrey, with her unlimited resources for a person trainer and private gym, can squeeze into a Size 8 for more than a month.

Peter1
Guest
Peter1

Maybe Lawrence you should give us some insight to your pristine and puritan life and habits so we can better estimate your risk to society.

B.Croson
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B.Croson

Stephen writes: “There is no magic bullet for solving the costly epidemic of obesity, but fining those who suffer from the condition is unethical, disrespectful, and counterproductive.” I agree with Stephen’s position on this issue. There are so many causal factors to this issue which go beyond what can be attributed to an individual to make punitive measures an effective, or warranted approach. There are systemic problems throughout the developed, and now developing, world that we collectively have contributed to the problem of obesity: improper food preparation and dietary choices, pervasive messaging through advertising, limited choices for transportation that compel… Read more »

Aurthur
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Aurthur

As opposed to the rest of ACA which punishes the many to benefit the few.

Quad
Guest
Quad

Wow, I had no idea I was such a victim until I read all these comments. Apparently I have no control over what food I eat or my weight. No one complained about smoking, substance abuse, or exercise so I hope we can agree that those lifestyle choices are important. Holding people accountable for decades of neglecting their bodies is hard, but is one of the few solutions we have to this crisis

Al Lewis
Guest
Al Lewis

Smokers rightfully take in on the chin in ACA — that was a clear choice and they need to and do pay the price. Weight was not a choice. My wife and her best friend have almost exactly the same diet but there is a 40-pound difference in their weights.

Quad
Guest
Quad

Except, of course, I the 7+ states who feel it would be discriminatory to charge smokers more. Heaven forbid we hold people responsible. Try harder.

Random Observer
Guest
Random Observer

Whoa. 90%+ smokers start before they are 18 (i.e. when they are children). Smoking is highly addictive. Did they really make a “choice” in the sense of making an adult informed decision about smoking??? IMHO, overweight individuals can choose to consume less food or burn more calories more easily than a smoker can choose to stop using nicotine. It’s just that the negative social and psychological impacts of being a smoker are so much greater thanks to a decades-long public service effort to properly demonize smoking. Not saying it is morally correct…but has anyone ever floated the idea of starting… Read more »

John
Guest
John

Glad to see the impact of these programs on the poor pointed out. The issue is NOT one of bad choices, laziness, sloth or immorality. A system with 70% overweight (which is a visible indicator of an underlying metabolic condition, not a health issue in and of itself) is a broken system; Americans did not all of a sudden lose their morals in the 1970’s. Big AG and Big Food make us sick, Big Pharma medicates us and Big Medicine manages the interface. We, taxpayers, pay for it when people get to Medicare/ And Pizza is a vegetable. Yikes………

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

Word.

John
Guest
John

Word word indeed. While we are at it, let’s deny climate change…..

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

Word again.

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

Not so obviously. Greed is at the root of it.

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

How about we fix our poisoned food supply? The meat, antibiotics, hormones, and artificial sweeteners….

Peter1
Guest
Peter1

Agreed Craig, “how about it” for sure, but it’s like saying, “How about world peace”. Almost impossible politically to attain.

Al Lewis
Guest
Al Lewis

dear Dr. Quack,

Agreed. These corporate obesity programs are really just the privatization of public health, punting problems to corporations so Big Food can say we are “doing something,” thus avoiding hard choices like a sugar tax and cleaning up some of the things you mentioned.

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

Agreed that this is impossible to attain. Greed that is sustaining it. But we can forget about controlling our diabetes/obesity crisis until we clean up our food supply.

Brad
Guest
Brad

Artificial sweeteners? Correlation does not prove causation. There is yet to be a causal link between the obesity and artificial sweeteners. A high correlation, but that might just be everyone that’s overweight making their healthy “choice of the day.”

Artificial sweeteners when consumed in moderation are still recognized as an effective way to help cut calories when attempting to lose weight.

nsv
Guest
nsv

Rebecca is quiet right. Furthermore, both fat people AND thin people get Type 2 diabetes, so assuming that fat is pathological does a disservice to both populations, by overdiagnosing fat people and UNDERdiagnosing thin people.

No one knows how to make fat people thin in the long term; indeed, much damage has been done to the health of fat people in the pursuit of thinness. Wouldn’t it make more sense for the ACA to encourage employers to pursue measures that would improve health? For a list of such measures, see Kate Harding’s classic, “On Problems to be Solved” (http://kateharding.net/2008/07/08/on-problems-to-be-solved/).