I admit that these things aren’t proven sciences. I know that I can’t say with certainty that a health person live longer than an unhealthy person. People die in accidents every day. However, the odds do favor the healthy person.

I think we have reason to take action before things are “proven sciences.” Even if you don’t agree that global warming is a problem, I haven’t found anyone saying that we should be hurting the environment more. If you are trying to build a successful sports team, do you throw up your hands and give up because it’s not a “proven science”? No you do the best the can with the information currently available to you. Five years from now, that information dictate that you should have done something different, but you are still better off using the information than doing nothing.

Perhaps poor people will still load their carts with unhealthy options. Perhaps they’ll try healthier options when healthy foods are cheaper. In fact, I’m sure that some percentage of both would happen.

“You may want to read the “huge burden” quote again. It was sarcasm of what a doctor would never say if people were healthy.”

I apologize. I did misread your quote.

Still, I’m not being obtuse. I understand your plan perfectly. You are confusing disagreement and personal conviction with the ability to understand the concept you propose.

You see fat people around you and conclude something must be done to make them healthier. Why? Well, the Good Samaritan in you believes if they lived as you do, eating organically and exercising moderately, they would ultimately be happier. You have also decided that another segment of our society, the poor, cannot sustain good health because they haven’t had access to the high-quality dietary foods you enjoy. Something must be done about that, too. But mainly, it is because you have decided that fat people are to blame for part of the ills associated with a broken health care system. They have caused an increase in your insurance premiums and become a burden to medical care givers. Unless something is done, it will only get worse.

You are using theoretical evidence to adroitly draw conclusions that may only be superficially true based on nothing more than conventional thinking. It certainly isn’t based on science.

Even with all the overweight unhealthy people that surround us, humans are living longer today than they ever have. Changing societal norms have influenced this but it has not been the driving force in any significant measure. Primarily, advances in medicine and health care have increased longevity. Additionally, human beings are not required to physically exert themselves from dawn to dusk simply to maintain a minimal existence as they did 120 years ago. We do not wear ourselves out merely to survive. This, too, has increased the life span of humans. You are also ignoring the fact that precepts for good health believed even 50 years ago are discounted as bunk today. Even the vaunted Food Pyramid is in its third rendition just in my lifetime. What does this mean? Perhaps what we are in is a natural ebb and flow of human existence. Perhaps there is no reason for you to step in and feed the poor apples and carrots. Perhaps I will live to ninety-four with minimal exercise and a high calorie diet. Perhaps you are simply allowing yourself to be manipulated.

Your global warming comment is a perfect example. This is not proven science. Forty years ago the prevailing thought in the scientific community was another ice age was burgeoning. We cannot say with certainty that global warming is anything more than a natural cycle of warming and cooling. But I would bet you’ve altered the way you live significantly because of it. You are living in the moment. That’s fine. But you are also proposing that others live in your moment by extrapolating data that may be true today but could be looked on by future earth dwellers as quaint. Science is not something you’re supposed to “believe in”. It is supposed to be a simple stable empirical truth; a physical law drawn from years of experimentation and observation which produces the same result and is universally accepted. This doesn’t describe the climate change theory you embrace. It doesn’t describe your position about unhealthy people. You cannot say with certainty that you will live longer than most fat people and with a better quality of life than they will have.

Finally, to state, as you and others have, that poor people cannot get fruits and vegetables gives the false impression that access alone would increase the odds they would consume them over unhealthy food. This is utter nonsense. In most cases, “being poor” is more a condition of “poor” lifestyle choices than it is a lack of funds. And I say that from personal experience. I don’t believe your plan will make the poor eat healthy foods anymore than I believe giving them a house will mean they will care for it in the same manner you and I do. (See Section 8 housing). Essentially, they will ignore your attempts at parental control and, forgive me, your rather self-righteous attitude about how they live, load their shopping carts with potato chips and beer and tell you to leave them alone.

You may want to read the “huge burden” quote again. It was sarcasm of what a doctor would never say if people were healthy. It does not indicate that the unhealthy people place a huge burden on society.

Ron, with all due respect, one example of yourself is not statistically relevant. You say that you pose no burden on me (and I’m not saying that I’m healthy either mind you), but that’s similar to one person saying that their SUV doesn’t impact global warming. Even if it doesn’t seem obvious, we know that it does.

When you say that my life is subservient to mine it shows me that you don’t understand what I’m saying. I wouldn’t deny anyone of unhealthy food. I would just raise the prices so that those who want to eat healthy have that option. You would still be able to buy any food that you can buy today. The difference is that someone poorer would now have an option (subsidized by the unhealthy foods) to eat healthy foods that are currently unavailable to him/her.

That’s what it’s about. It’s not denying anyone of their chosen lifestyle. It’s solving a problem where people often have to make a tough choice between their wallet and eating healthy.

Globally, black market cigarettes make up 11% of all cigarette purchases at a cost of 50 billion in lost revenue. (http://www.havocscope.com/trafficking/cigarettes.htm)

Your plan would create multiple black markets. But that is not really the main point.

I’ve noted that as this discussion has progressed your description of this issue has become more acerbic. You began by saying your reason for promoting this idea was to save healthy people 20% in insurance premiums. Your last comment indicates your desire to save our society from the “huge burden” unhealthy people place on them.

I don’t know you but I would guess that in your estimation I’m unhealthy. And yet, I pose no burden on you. I work everyday, take care of my family and I’ve only been to a doctor, on average, once every 10 years if you exclude dentists and eye doctors.

I’m 42 years old. My life, for all intents and purposes, is probably half over. Perhaps, if I’m lucky, I’ll get 10 more years and live to 94. So the question for me comes down to this. Can I have all the things that make life that much more gratifying to me, things that make my life just that much sweeter, as eating organically and exercising does for you? If my definition of a satisfying life is just as important to me as yours is to you, why do you get to decide that mine should be prohibited, in any way, by the government?

If you will allow me to argue a point you haven’t made, please don’t compare what we are talking about to drug or alcohol abuse. I’m not an addict. I live in a free society where I’m allowed to be as healthy or unhealthy as I want to be within the physical parameters God gave me. Again, what we are talking about here are functional people who are simply living a lifestyle you don’t agree with.

So, how about it? Why is my way of life subservient to yours?

It’s not the hardest thing in the world to tax products. We already do it with gas, alcohol, and cigarettes. Yes this is a little more complex, but it’s not like the entire wheel is being reinvented.

It’s possible that my plan could be implemented at the state level. It might open up new problems and holes, but again that’s someone whose career it is to iron it out.

Prohibition made alcohol completely illegal, not more expensive. Cigarettes are a good parallel. There’s a bit of a black market there. However, I think that 99.9% buy them legally and pay a huge tax over what their cost of production. The good far outweighs the bad.

Oakland: You know why people don’t have access to healthy food… it’s because it’s currently too expensive. You open up a fruit store and charge $1 an apple and the cash-strapped person is going to take the nearly 400 calories of a double cheeseburger every time. The fruit store goes out of business – the economics currently in place don’t support it. If fruit is suddenly the thing that is cheap and the cheeseburger is expensive, Walgreens quickly adds an extensive fruit section. There’s no physical issue of getting produce to Oakland, plenty of it is grown just a few miles awhile.

“And as I mentioned, he forced himself to consume every bite of food that he ordered. Heck, if I force fed myself grilled chicken breasts to the gills at every meal for 30 days, I’d probably also mess up my health.” That’s part the point of SuperSize Me. It’s not just that the food is unhealthy, but it’s also that the portion size is out of control (hence SuperSize). Did you see what the size of fries and soda were in the 70s vs. today.

Of course a healthcare titan is going to say that increasing preventive care is the worst cost containment strategy. He’s absolutely right. If I go to the hospital everyday thinking I’ve got a new disease and want to be tested for it, costs are going to be crazy. I don’t suggest that. If that’s what the healthcare titan is seeing, he/she needs to address that separately from my plan.

I invite your plan to go out and test my theories in the real world, but I don’t see what can become of it. At best, I’d get a few single points of data. It’s like watching one at bat of a baseball player, the sample size is too small. I have worked in a hospital (pharmacy technician) for years. I have talked to physicians about the problems they see in our health care system – they’ve got many more ideas to implement. I have not met one who said, “I wish there were a way to make people eat unhealthier. Everyone is consuming too many fruits and vegetables and showing up for check-ups at the perfect weight and in good health. It’s really going to be a huge burden for society.”

Yet again, Lazy Man, you are demonstrating how naive you are about legislative and regulatory processes. “A few different food regulations” doesn’t even begin to cover it. The cost to the Federal government for determining your fat tax would most likely outweigh the taxes reaped. I do think it’s great that you’re thinking outside of the box. But please, read up on how government agencies regulate and what it involves. The repeated retorts of “my plan will fix that” doesn’t adequately address the issues that many have raised.

Additionally, we have no sort of Federal tax on retail goods in this country. The Department of the Treasury would have to set up an entirely new system to collect your fat tax. And where there’s dollars collected by the government, there’s also fraud. You’ll also need oversight to determine that the tax is being properly collected. If you want to get some sense of what implementing laws costs, read reports from the Congressional Budget Office.

And just like prohibition, you are creating the best situation for food to be sold on the black market to circumvent the tax.

“Again the fact that people in Oakland may only have a choice of Walgreens is a topic completely separate from my plan.”

It is absolutely not. Many Americans lack access and means for high-quality healthy food. So it’s ethical to put these people more in the hole?

“I loved Supersize me. I’m skeptical of the article you listed since it just said that she had to have everything on the menu once. ”

I knew you did! Be equally skeptical of Spurlock. From a review of the movie posted here:
http://www.glidemagazine.com/index.php?task=Articles&section=94&id=46548&issue=1
“Spurlock eats by the rules of ordering everything on the McDonald’s menu at least once, and only super sizes upon being asked.”

And as I mentioned, he forced himself to consume every bite of food that he ordered. Heck, if I force fed myself grilled chicken breasts to the gills at every meal for 30 days, I’d probably also mess up my health.

And a couple of other points:

* Kitty’s right about your overestimation of the impact that eating health really does have, as well as the impact of prevention. I lunched today with a friend who’s an executive with one of the biggest healthcare titans in the nation. To quote my friend, “Increasing preventive care is the worst cost containment strategy.”

* Lastly, I seriously urge you to, offline, go and test out your theories about weight and “unhealthy foods” and illness. Do some volunteer work at a community health center or food bank. Talk to people battling MS or end-stage renal disease. Talk to people with costly mental illnesses or eating disorders exacerbated bt the notion of “good” food and “bad” food. Talk to physicians about what they see as the problems with the costs of our healthcare system. Visit a poor neighborhood and see how people live and where they buy their food. In other words, see how your theories stand up in the real world. I have done the things I mentioned in this paragraph, which shaped the points that I have made here.

I do think you overestimate the impact of eating healthier. We know that being obese increases risk of some conditions but not nearly to the extent that smoking increases risk of lung cancer (and most people still don’t get lung cancer). What about two thin people – one eating more fat another more of the food you consider “healthy”? I mentioned WHI study that showed no difference in outcomes between low-fat group and the controls. Do you have any other study? Can you quantify the results e.g. per 1000 people and adjusted by age (most people gain weight when they are older) and genetics? All you have is your belief, but all the evidence so far shows pretty modest impact of lifestyle choices. Women still go to menopause at around 48-52 on the average, and once they do their risk of heart desease increases, their risk of osteoporosis increases, it becomes much more difficult to maintain weight, blood pressure and cholesterol go up more or less depending on genetics. No amount of healthy lifestyle can postpone the menopause as well as other results of aging.

Additionally, as it was said above, you are only postponing some conditions, no eliminating them. In some cases you are replacing them with others. So we may see less diabetes, but more osteoporosis in women or prostate cancer in men. How would this reduce the total number of hospital admissions?

I’d also like to second what M said about not trusting the government, insurance managers to know or understand the evidence and to quickly react when the evidence changes. Doctors cannot agree on the evidence – look at the recent discussions (post-ENHANCE trial) on value of LDL cholesterol measurement in many doctors blogs. How would you expect politicians to interpret this? Many current proposals for P4P emphazise blindly following the guidelines – e.g. achieve specific metric without regard for individual risk and variability or even conflict of interests in those who come up with the guidelines (e.g. are paid by pharmaceutical companies). Another example is Edwards’ plan to mandate annual physicals hoping that it’d reduce costs. This was happening after most medical journals and USPSTF concluded that annual physicals are useless for most people and that while some specific tests are recommended at specific age and specific intervals most annual physicals include not only non-recommended tests but also tests that USPSTF recommends Against because “harms likely to outweight the benefit” and waste a lot of money. So how can you trust the government and politicians to figure out what is right and to timely react to evidence changes when the doctors themselves don’t react that fast?

Again the fact that people in Oakland may only have a choice of Walgreens is a topic completely separate from my plan. My plan wouldn’t make this situation worst, and it might even be able to make it better.

I loved Supersize me. I’m skeptical of the article you listed since it just said that she had to have everything on the menu once. Well that can be done in first 7-10 days more than likely. From there on out she could have salads if she wanted to. She also could have meals that are completely atypical of the average customer – “My favorite meal? A medium chocolate shake with medium fries.” People typically have a drink, fries, and sandwich, the components of a value meal. I’m sure some have diet coke for the shake and get a sandwich (about the same calories), but others still get the sandwich and shake.

It’s easy to eat healthy at many fast food places. However, there’s no escaping that the average Value Meal (what most people order) is more calories than most people should have for their 3-squares. I think Morgan Spurlock went with the average meal that people eat and I think she might have gone for lighter meals. I would love to compare the meals side by side. I’m sure Morgan Spurlock didn’t have fake doctors give him fake results.

“It wouldn’t require a change in the law that would take years, just an update of “healthiness score” of the foods.”
Don’t forget that criteria would have to be established by law and regulation that would move at a snail’s pace. Additionally, the regulation of food in America is divided among federal agencies. For a frivolous yet true example, cheese pizza is overseen by the FDA, which is part of Health and Human Services. But pepperoni pizza is overseen by the USDA. Heck, nobody can agree on what the food pyramid should be, never mind what constitutes “unhealthy food.”

By the way, you should also consider that we have enough of an eating disorder problem in this country, and it’s been proven that designating foods as “good” or “bad” in one’s mind doesn’t help matters. Imagine the effect of having the goverment mandate these labels.

“When you are volunteering at a local food pantry, are you happy with the quality of food that you are making available? It sounds like you are not.” My point with saying that probably wasn’t as clear as I wanted it to be. What I was trying to say that keeping tabs on preexisting conditions are less of a concern to those folks because they have other things to deal with.

Concerning the quality of food – I’m OK with it. The food pantry I volunteer at does provide clients with a bag of fresh vegetables, and the pantry foots the bill for these. The other food comes from the area food bank. The food bank obtains its food from donations that come from grocery stores. So yeah, they get what they get. But typically, clients receive canned vegetables, rice, pasta, cereal, peanut butter, tuna, etc. They also give out cake mixes and snack foods.

“I don’t live far from San Francisco which has a huge homeless population – yet I don’t see where it’s hard to find fresh food.” The homeless aren’t shopping at Safeway. I’m talking about the urban poor and people who live in the projects. I would venture to guess that this is an issue in Oakland. In a few urban areas of the U.S., I’ve seen people shop for groceries at Walgreen’s because that’s all there is.

“The more healthy people, the less crowded hospitals are and the less busy doctors are.” True, to some extent. Not all illness is caused or exacerbated by eating junk food. End-of-life care in America’s a huge expense, as is caring for individuals with psychiatric illnesses and Alzheimer’s.

One other comment. I hated the movie “Supersize Me.” I rented it on dvd and shut it off after Spurlock force-fed himself a supersized extra-value meal and subsequently vomited. Force-feeding oneself anything until you puke, even vegetables, isn’t good for anyone. I felt that the movie lost credibility with that scene. But that movie’s been the symbol of “unhealthy foods” being the root of all evil. Consider the story of Soso Whaley, a New Hampshire woman who ate only at McDonald’s for a month (and did the experiment two more times) and dropped weight and lowered her cholesterol.
http://www.nationalreview.com/interrogatory/whaley_200506230747.asp

Fruits and Vegetables: Sure how about farm subsidies. I don’t know how farm subsidies work, but it sounds good to me. I’m not an expert, but I could find experts. Maybe the government could pay each farmer more money for every apple produced. This is not an unsurmountable problem.

Revising the Tax: It wouldn’t require a change in the law that would take years, just an update of “healthiness score” of the foods. If the system says that Doritos are twice as unhealthy as the average food, it’s tax falls in that 2x bucket. If we find that Doritos are twice as healthy as the average food, it’s tax falls in the 0.5x bucket. The law would apply to taxing of the buckets, and a Food/Health committee would review foods on a regular schedule. Law stays the same the classification of the food changes.

“My eating a plate of wings and fries around you doesn’t affect your health.” No the physical location of you eating wings will not hurt me. However, I drive my car in Nebraska and it hurts the icebergs, penguins, and polar bears. It’s the same effect. The more healthy people, the less crowded hospitals are and the less busy doctors are. It’s not a direct effect like smoking or stabbing someone with a knife, but I don’t see how there is any doubt about the indirect effects.

I’m sorry you found my response smug. I propose something that would make things better, and suddenly I’m expected to solve additional problems like getting healthy food to the poor in an undisclosed place that I’m not aware of. I can’t begin to speak about the logistics of that problem. I don’t live far from San Francisco which has a huge homeless population – yet I don’t see where it’s hard to find fresh food. You might just have to pay for it (which is what I’m proposing we change).

Maybe this answer will be better. Yes, let’s let the government make healthier food available to the poor. Let’s fund that effort with the “fat tax.” When you are volunteering at a local food pantry, are you happy with the quality of food that you are making available? It sounds like you are not. The reason is likely that it’s very cheap food. If this cheap food was made more expensive, and the quality food was made cheaper, you’d be serving very cheap, quality food. This seems like good thing.

I’m not trying to be smug, but I’m simply trying to solve a problem, the poor can typically only afford unhealthy foods, while middle class and rich can choose to pay extra for the healthy alternative.

“The “fat tax” is not a tax on “fat” it is on unhealthy foods, however we currently define it. Right now we think that high-fructose corn syrup is unhealthy.”

Who’s “we”? There’s a powerful lobby of corn farmers in the Midwest as well as several powerful national corporations who would beg to differ, I’m sure. And they have the cash to lobby Congress, who would have to pass such a law. I’m not saying that I disagree with you re: high fructose corn syrup, because I don’t. But government right now sure doesn’t feel like hfcs is “unhealthy”, despite “conventional wisdom” because it still sweetens our food supply.

“Thus it would be taxed fairly highly and the savings would be passed onto to fruits and vegetables.”

How so? Farm subsidies? Produce vouchers for low-income Americans? Putting Whole Foods in the ‘hood?

“If five years from now high-fructose corn syrup becomes the healthiest thing in the world and fruits and vegetables become known as unhealthy, we reverse the tax and fruits get expensive while high-fructose corn syrup becomes cheap.”

Time for a little civics lesson. Assuming a law was passed that created the “fat tax” that you propose, reversing the tax would require some federal agency to issue proposed regulations, provide a comment period, then finalize the regs. In most cases, that process taxes years. Yes, years. In the meantime, we could find out that Doritos contain antioxidants that could extend our lives for decades, yet Americans don’t eat them because they cost the same as a dinner at Pastis.

““When the fat tax does not work (taxing sin never has)”… I refer this Wikipedia reference, “It has been shown that higher prices for cigarettes discourage smoking. Every 10 percent increase in the price of cigarettes reduced youth smoking by about seven percent and overall cigarette consumption by about four percent.” Sounds like it would work.”

My eating a plate of wings and fries around you doesn’t affect your health. My smoking cigarettes (if I smoked) does affect your health. There’s also a social stigma associated with smoking that doesn’t exist with “unhealthy foods.” If that was the case, then there wouldn’t be Super Bowl parties.

And lastly, I have to admit that I find a heck of a lot of your reasoning on this issue to be quite smug. I commend you and your wife for managing your pre-existing conditions. But come on, you also have a substantially higher standard of living than a large percentage of Americans. I volunteer at a local food pantry, and it’s alarming to see the number of unemployed folks who I’ve talked with who never thought they’d have to resort to standing in line on a Saturday morning to get a small supply of groceries and had to choke down their pride to do so. I’m sure that some of them have pre-existing conditions, but trying to get by on a day-to-day basis is enough for them to handle. I also refer to my earlier point about the lack of fresh food in low-income neighborboods. In response, you wrote, “I’m not familiar with these places, but I have to figure that if we are collecting more money for bad food, we can make good food more available.” Again, who will be doing that? The government? Private industry getting government subsidies that likely won’t trickle down to the consumer level?

But when you start talking about requiring the “unhealthy” to pay more of health insurance, you are talking about cost to others and this is where you get into a situation where there is some (maybe flawed) evidence that “unhealthy” cost less vs no evidence to the contrary. Also, dying at 10 is an extreme example. For the most part unhealthy lifestyle doesn’t cause one to die at 10, but maybe at 60 vs 70 or 70 vs 80. Some people are productive in their 70s, but most want to retire earlier if they can. So we aren’t really talking about most productive years of life.

Additionally, it is extremely naive to think that healthier lifestyle will have any measurable effect on people’s productivity into their 70s. Getting older is the biggest risk factor for most conditions: heart desease, cancer, arthritis, osteoporosis (low weight is actually is risk factor). Some of these may be affected by lifestyle choice, most – aren’t. And even healthy people suffer from memory loss as well as loss of physical strength – so it is extremely naive to think that “healthier” lifestyle will have significant effect on productivity “past our 70s”. A small one – maybe, but not significant.

This example shows that economically there’s some value to at least living until a certain age. As we become healthier, we are more able to be productive past our 70s. I think is an argument for healthier living so that we can continue to be productive as long as possible.

I agree with you. We have to come to grips with our mortality if we are to have an affordable health care system.

I still take issue with your presentation of these studies. They only report the *absolute cost* of health care, not the net cost or relative cost. For instance, obviously if an unhealthy person dies at age 10, they will cost very little compared to a healthy person who has a few minor surgeries over an 80 year lifetime. BUT which one contributed more to society economically? Obviously the person who lived long enough to have a good career and pay taxes. You never attempt to address that part of the issue.

“Cost of open heart surgery for the neighbor: $60,000+”
But none of us is mortal. Everone dies at the end, and while some of both “healthy” and “unhealthy” die instantly in their sleep, many get sick at the end. 2/3 of women will eventually die of heart desease. Healthy lifestyle doesn’t entirely prevent the desease, it postpones some of them or replaces them with some other desease later in life. So the real question is what is more expensive an open heart surgery at the age of 50 (who may then die at 55) or open heart surgery at the age of 80 who may then die at 85. You may say that the person who needs open heart surgery at 50 ma live longer while sick, but the person who lives healthy lifestyle may be treated for “risk factors” before that, and years of prescription drugs and even recommended screenings and other tests add up as well.

You said, “Profit Margin – shall we compare profit margins of the insurance and hospital industry? I’ll assume not.”

Why not? I’d love to see a comparison. I’d love to see the salary breakdown as well, since you’ll surely deduct salaries from the hospital’s profit.

“One of the large insurance companies that my hospital contracted with would not give their fee schedule. The fee schedule is the table that tells us what we’ll be paid for certain procedures. If I don’t contract with them, I’ll have thousands patients furious that I no longer take their insurance. The insurance companies know this and use it to their advantage.”

Heh maybe you’re just trolling. Why are you concerned about angering those patients and not the hordes of other patients who are subsidizing the price discounts? Or why don’t you give the discount to everyone? It’s obviously still profitable or you wouldn’t accept it.

You said, “We used to be a nation that has a sense of community. When your neighbor was sick you’d check in on them to make sure they were OK, maybe take them a bowl of soup.”

Cost of soup for the neighbor: $0.30
Cost of open heart surgery for the neighbor: $60,000+

You really need to understand the changes that society has gone through since the “sense of community” you’re talking about was prevalent. Do you realize that health insurance didn’t even exist back then? The reason is that there WERE no expensive procedures. Fixing a broken arm didn’t break the bank. If you had a heart attack, you died.

We’ve made incredible advances in health care and since it’s so highly specialized it costs a fortune. Everybody wants access to that highly specialized care.

“This isn’t just about money, this is about basic human decency.”

This is 100% about money. If all you care about is “basic human decency” then that requires nothing more than easing pain. We would not need insurance at all.