Amidst inflated prices, changes in health care coverage and overall dissatisfaction with health care in the United States, America’s problem with obesity continues to be ignored.
Obesity has dramatic impacts on our overall health and increases the risk of developing numerous chronic health conditions: heart disease, diabetes, cancer, asthma, arthritis, sleep apnea, infertility, stroke, dementia, multiple sclerosis, depression, gout, liver disease, erectile dysfunction, and kidney failure, just to name a few.
Chronic disease is one of the main drivers of rising health care costs in the United States. Direct health care cost estimates related to obesity in the United States range from approximately $100 billion to $200 billion per year, comprising between 5% to 12% of total U.S. health care spending and a per-person direct annual cost of $1723. Given the unique structure of the American health care system and the insurance market, this raises two questions: should obese individuals pay higher premiums to cover this excess health cost, and, have the provisions outlined by the Affordable Care Act (ACA) succeeded in reducing the prevalence of obesity in the United States?
The ACA sought to reduce the health care burden of obesity through several provisions. One provision was to remove the ability for insurance companies to discriminate based on pre-existing medical conditions. Obesity was considered a pre-existing condition prior to the ACA by many insurance providers and as such, millions of Americans were denied care or charged higher premiums on the premise of the associated health care risks. Many private citizens praised the mandate against pre-existing conditions as a way to reduce discrimination, while economists and insurance companies have blamed the mandate as a reason for higher premiums, arguing that obese individuals increase the risk pool for a given insurance network and, as such, increase prices. Other U.S. insurance markets, such as life insurance, are not restricted by a pre-existing condition ban and so charge obese individuals more to cover the excess health risks. Whether or not there is an economic incentive or a “moral obligation” for insurance companies to cover pre-existing conditions one fact has been made evident by the recent failure of the American Health Care Reform Act of 2017; once a ban on pre-existing conditions has been introduced, it is tantamount to political suicide to try to remove that ban.
In addition to preventing insurance companies from charging more for pre-existing conditions, the ACA included several other provisions to directly reduce the health care burden of obesity. These included a federal match for preventative services, state aid in designing public awareness campaigns for Medicaid enrollees, and funding for the Childhood Obesity Demonstration Project to promote healthy living among low-income children.
Unfortunately, it is not clear that these provisions have succeeded in significantly altering America’s obesity trend. Between 1990 and 2010, the percent of obese American adults increased from approximately 11% of the population to 27% of the population. Between 2011 and 2014 that number increased from 34.9% to 37.7%. The trends in obesity among children and adolescents over the same time-period have fared slightly better, increasing from 10% to 17%. However, since 2008 the prevalence of obese 12-19 year olds has increased (18.1% to 20.5%) and the prevalence of obese children under 12 has decreased (Pooled prevalence of approximately 15% to 13.2%). This indicates that, while the ACA might not have succeeded in reducing nationwide obesity prevalence yet, it may be helping to reduce the prevalence of obesity among children under the age of 12.
The intersection of nationwide trends in obesity with insurance coverage, analyzed by ethnic group paints a stark picture. In 1988, 21.1% Black men were obese and 23.9% of Mexican American men were obese. In 2014, 38.0% of Black men were obese and 42.2% of Mexican American men were obese. The data is much starker among their female counterparts, who saw an increase in prevalence of obesity from 38.4% to 57.2% and 35.4% to 50.9%, respectively. Mexican American and Black women represent the two populations with the highest prevalence of obesity in the country. Blacks and Hispanics are also the ethnic groups in the United States most likely to lack any form of health insurance. Therefore, there is concern, that were insurance companies to increase health care premiums for obese individuals, it would adversely affect an already disadvantaged group and potentially drive those patients out of the insurance market altogether. Charging obese individuals higher premiums would most likely backfire and lead to a net increase in premiums for the remaining insurance pool when uninsured, obese individuals come to the hospital with emergent, significant, co-morbid medical concerns.
Looking forward, the current political administration has many opportunities to decrease the health- and cost-burdens associated with obesity. For example, restructuring prices in cafeteria settings to favor fruits and vegetables, and introducing health education programs have significantly reduced the volume of food consumed by adults and increased the proportional-purchase of low-fat foods in some studies. The introduction of school-nutrition and exercise programs reduced the mean body weight of school-aged children by 29% (95% CI [45% to 14%]). Additionally, living in geographic areas with urban-planning policies to increase safe physical walking spaces, increase the quality and quantity of local parks and design buildings to emphasize the use of stairs over elevators or escalators is significantly correlated with reduced prevalence of obesity even after accounting for pertinent confounders, such as socioeconomic status and food availability. Thus, it seems there is an excellent opportunity at hand. President Trump has called for a $1 trillion investment in infrastructure. The direct, per-year obesity-attributable spending of just Medicare and Medicaid is approximately $100 billion.
If that infrastructure investment used urban-planning policies to help increase physical activity and increase access to healthful food, it could potentially pay for itself in 10 years while simultaneously alleviating one of the largest health care burdens in the United States.
Obesity is an epidemic in the United States. It is an epidemic that is claiming the lives of our citizens, making the people of this country sick and costing our country hundreds of billions of dollars every year. It is an epidemic that is worse than smoking, worse than opioid abuse and in many ways, worse than even cancer, diabetes or heart disease as it increases the risk of developing those conditions and potentiates the severity of those conditions. Public health policies to reduce obesity will be a driving factor in curing this epidemic. The only questions are how much money and how many lives are we willing to sacrifice until we actually fix it.