I happened to post a link to an article in the News & Observer today, "N.C. to impose 'fat tax'", on my Facebook page and I couldn't believe how many comments were generated there, opening up a somewhat heated dialogue revolving on the "blame the fattie" meme. So I decided to post it as an entry here for discussion. First, the news article:

North Carolina is poised to become only the second state to impose a fat fee on its state employees by placing them in a more expensive health insurance plan if they're obese.

Smokers will feel the drag of higher costs, too, as North Carolina state employees who use tobacco are slated to pay more for health insurance next year.

State workers who don't cut out the Marlboros and Big Macs will end up paying more for health care. Tobacco users get placed in a more expensive insurance plan starting in July and, for those who qualify as obese, in July 2011.

...The policies have generated a backlash among at least a portion of state workers. Some workers are anxious about the idea of tests for smoking.The tests involve examining a saliva sample for cotinine, a derivative of nicotine found in the system of tobacco users. Health plan officials recognize those concerns and are getting ready to take bids from companies that will perform the tests. The state plan has not yet developed a procedure to monitor members for the obesity standard due to take effect in 2011.

That last line says it all. There are serious problems with this policy that you don't need a medical degree to see are going to crop up.

Is all obesity the same? No, but it's treated in this policy as if it's all about "stop shoving Big Macs in your mouth." Obesity is a complex problem; if it were that easy to lose weight and keep it off, everyone would be thin, and we'd already have a pill that is safe, effective and can be taken long term. Speaking of pills, many medications to treat other illnesses (diabetes, depression) are the documented cause of substantial, sudden weight gain that is almost impossible to shed.

For fibromyalgia, for example, I refused to take Lyrica because it was associated with too many cases of weight gain, as in 30-60 lbs(!). On message boards I surfed, there were people so fraught with pain, and who never had a weight problem, suddenly finding themselves obese, but with reduced pain. Will NC employees in similar situations be told to stop those medications? I doubt it, but how does that solve the policy problem? If the state really cares about the health of these people (instead of naked costs), then they would have thought this through.

The no-win situation. The state says in order to stay in the 80/20 plan (the insurance pays 80%, the employee 20%), your BMI must be under 40. So if you kick your butt in the gym, do Nutrisystem or whatever plan of the month is, and gut bust down to 39 BMI you should be good to go, right? Nope. The state moves the goalposts the next year, because they lower the BMI qualification to 35. Sweet.

The onus is solely on the employee. The logical question is, will insurance then cover bariatric surgery for those who want to make the BMI goal? Something tells me I doubt it. Will it cover weight loss programs? What if the employee has two jobs and kids and can't afford any gym membership, let alone the time to go? Is that person then punished with a higher premium?

What about yo-yo effect. It's well-known that calorie-restricted diets simply don't work. The weight does come off, but the vast majority of individuals put the pounds back on over time, and some end up even heavier than they were prior to dieting. The cycle of yo-yo dieting and the strain it places on the heart is well-known as well. Did the state take this into consideration? How about when you yo-yo and go over 40 BMI, drop to 35 and go back up to 40 -- do they keep switching you back and forth between plans?

As I said, on my Facebook page, the discussion escalated quite quickly. See some of it below the fold.

And there are a lot more comments. I'm sure these are similar to many conversations going on around the state about this not-well-thought-out policy and its ramifications. All it says to me is that health insurance reform cannot come fast enough to stop madness like this.

One commenter, Matt McNeil, boiled the solution down to this:

Whatever happened to taking personal responsibility?

My response:

I hate to break it to the "blame the fatties crowd" but there are a lot of reasons people are obese besides overeating. That's one factor, but so is the proliferation of the use of anti-depressants handed out by doctors, many of which cause weight gain, and in some cases significant weight gain. What then -- go off the meds to make the BMI? What about endocrine-based conditions that make it difficult to lose weight, such as PCOS? How about diabetes -- the use of insulin does come with increased weight gain for some, so diet and exercise alone is not that simple.

His reply:

Rare conditions aside, truth be told, folks should still take responsibility for their health. I think we can all easily distinguish between obesity caused by medication and/or rare genetic conditions and obesity caused by (yes, I'll say it) sheer gluttony and poor food choices. As for the issue of income, well, this is the first time in human history that poverty and obesity have been linked so closely. Even poor folks can read (or at least listen) and decide to go with beans or tuna in lieu of McDonald's and Pop Tarts. As my granny used to say, "We're poor, but we keep the house painted and the lawn mowed." Poverty is not an excuse for shirking personal responsibility. Same with cigarettes, alcohol and other drug abuse. Letting someone off the hook because he or she is poor is no better than letting someone off the hook because he or she is rich. My granddad barely scraped by with a high school diploma. He picked cotton 'til his hands bled and milked cows from dawn 'til dusk, but he knew that if you ate the wrong foods and sat on your duff, you'd get fat. He didn't try to blame genetic disorders, nor did he try to blame his low income. He worked hard and stayed lean and fit until he died at 91.

Others responded to him to get him to understand the complexity of the situation, as blame alone hasn't ever worked, and that people were interested in discussing possible solutions. I replied:

But you didn't respond to the yo-yo dieting factor. Even if motivated to do so and succeed at losing weight, all data suggests that more than 85% of people gain it back and another percentage add even more than when they started. That's not news to those in medicine. So either they need to fund a more permanent solution (saying stop eating too much clearly hasn't worked, labeling of foods hasn't worked), what do they have to offer other than a stick -- there's no carrot? There's personal responsibility and then there's the reality of what has not been accomplished. People have sedentary jobs, work longer hours, and nothing about the American workplace or ethic promotes health.

If you're poor and supporting children and working two jobs, should they be punished for not putting the hours in the gym they cannot afford to get that discount? I'm just trying to be realistic in assessing whether this policy of financially punishing obesity will be effective (as opposed to smoking -- you either do or don't smoke, you cannot choose not to eat at all so they aren't equivalent).

If the state wants to say it's trying to reduce costs by "fining" smokers and the obese, fine, but that's not what they are saying -- they are couching it as trying to improve employee health -- it's not clear whether they want to shell out the insurance dollars for a more permanent fix for obesity that is available to all, regardless of socioeconomic status.

Others chimed in.

Bird Williams: "Putting too much into their gobs" may be a smug attempt at fat humor, but it hardly addresses the facts. Medical research makes it plain that a person's weight is not a very reliable indicator of overall health. In fact, recent studies indicate that 50% of the overweight and 33.3% of the obese are "metabolically healthy" while 25% of the folks in the so-called "healthy" BMI weight range have two or more cardiovascular risk factors, perform poorly on treadmill tests and, while they may avoid putting anything "into their gobs," they are hardly healthy or, by extension, in a category that should quality them for less expensive health insurance by NC's formula. Check out this overview of recent obesity research from The Archives of Internal Medicine, the Centers for Disease Control, and the National Cancer Institute at http://www.nytimes.com/2008/08/19/health/19well.html?_r=1&th&emc=th

Ryan Villalpando-Long: Yes people can change their habits. But, again, we should treat this like a genuine health problem to be solved, not a character defect.

If people are not educated and given healthy options, they won't be able to take "personal responsibility" because they won't have any. Also, our health care system focuses on fixing things when they break, not developing healthy lifestyles and maintaining good health throughout life.

"Personal responsibility" should apply to us as a society, not to the fat person alone.

Camille Klein: "I hate to break it to the "blame the fatties crowd" but there are a lot of reasons people are obese besides overeating."

Pam, didn't you get the memo? All us fatties have to do is lose weight, and our problems will magically be solved!

Matt and the rest of the fatbashers: I eat healthy foods in small portions (your average restaurant meal is one week's worth of lunch and dinner for me), I try to exercise as much as I can, and I can only keep my weight stable--not gaining, not losing--thanks to PCOS and the insulin-resistance that goes with it. Not even taking Glucophage is helping me lose weight, and I flatly refuse to mutilate myself by getting a gastric bypass (especially because it will not do anything at all to solve the underlying issue).

What do you suggest I try next, stop eating altogether? How about I self-terminate--will that make you happy? After all, it'll be one less fattie driving everyone else's insurance rates up! In short: fuck you, pal--I am busting my ass to try to bust my ass, and fatphobes like you do nothing at all to help with your condescending "well maybe if you weren't fat in the first place then you wouldn't have a problem" attitudes.

So, where do we go from here in terms of problem solving. It's clearly an emotional issue, partially because this health insurance policy is tacitly endorsing a fat-bashing, fat-shaming philosophy that is definitely perceived out there as a stick, not a carrot. So that's a big PR problem.

What's most disingenuous is that it is being framed as your employer being "concerned about your health" when it is really about reducing costs quickly -- witness the no-win BMI situation that shows the hand. There's nothing wrong with being frank about reducing costs, but then be serious about how it is going to be accomplished if the goal is to help people get down to a healthy weight. With so few details about how measurements will be handled, it's pretty clear that there was no plan.