Nanny State

Is Your Flab Imposing a Burden on Society?

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"As economists put a price tag on sky-high body mass indexes," Reuters reports, "policymakers as well as the private sector are mobilizing to find solutions to the obesity epidemic." The story lumps together all sorts of obesity-related costs, without regard to who pays them or why. It worries that people have to buy more gasoline to transport their bloated bodies, for instance, and it says the lower wages earned by obese women amount to "a $76 weekly obesity tax," although these costs are borne by fat people themselves and therefore hardly count as externalities justifying government intervention. Reuters likewise counts the cost to employers of obesity-related absenteeism and "presenteeism" (reduced productivity), although businesses can take such costs into account when deciding whom to employ and how much to pay them (which could help explain the relatively low wages of obese workers). But mainly Reuters worries about obesity-related medical costs, citing a recent study that puts them at $190 billion a year in the United States, more than twice as high as previously estimated.

That study, reported in the January issue of the Journal of Health Economics, is based on the same data source as the earlier estimate (which comes from research led by Duke University health economist Eric Finkelstein): the Medical Expenditure Panel Survey. But instead of the body-mass index (BMI) reported for each adult, the authors, Cornell economists John Cawley and Chad Meyerhoefer, used the BMI of the subject's oldest biological child, on the theory that respondents would be less apt to understate their children's weights than their own (or their spouses). Since "there is a strong genetic component to weight," Cawley and Meyerhoefer reasoned, children's BMIs should be a good indicator of their parents' BMIs. They also hoped this indirect measure would control for the possibility that people gain weight "after suffering an injury or chronic depression," which would lead to a noncausal association between obesity and health care spending. Cawley and Meyerhoefer say their approach identifies "the causal effect of obesity," as opposed to earlier studies, which gave us only "the association of obesity with medical care costs." 

As they later acknowledge, that is not quite true. In theory, using children's BMIs as proxies for their parents' BMIs allows Cawley and Meyerhoefer to measure the association between a genetic predispositon to obesity and medical costs. They argue that "the preponderance of evidence" indicates the impact of a "shared family environment" is "so small as to be undetectable and ignorable." But even assuming that's true, the authors concede, a predisposition to obesity may be associated with other genetic factors that boost medical expenses. In fact, if the predisposition to obesity is really a predisposition to dislike physical exertion and eat large amounts of high-calorie, low-nutrient food, lack of exercise and poor diet could be the main causes of ill health, as opposed to extra pounds per se. 

A closer look at Cawley and Meyerhoefer's data casts further doubt on the importance of government-recommended BMIs. Unlike earlier studies, their cost estimate compares the obese to the nonobese, included people deemed "overweight," whose medical costs are about the same as those of "healthy weight" (and who actually have lower mortality rates than people in the "healthy" range). For men and women together, the researchers note, "expenditures fall with BMI through the underweight and healthy weight categories, are relatively constant with BMI in the overweight category, then rise sharply with BMI through the obese category." 

Looking just at men, "expenditures drop sharply with BMI through the healthy weight category, fall modestly with BMI in the overweight category, then rise slowly at first then sharply with BMI in the obese category." In other words, higher BMIs are associated with lower health care costs among men, even after they pass a BMI of 25 and are officially considered "overweight." In fact, "the BMI value associated with minimum expenditures for men is roughly 30," the dividing line between "overweight" and "obese." For women, the picture is different:  

For a wide range of BMI, roughly 15–25, expected expenditures are relatively constant. As BMI rises beyond 25, however, expected expenditures rise through the overweight and obese categories, increasing rapidly at the high end of the obese range.

The difference in health care spending between obese and nonobese women is statistically significant, but the difference between obese and nonobese men is not. These sex differences may have to do with the weakness of BMI as a measure of obesity, since men are more likely to build extra muscle, which can make a fit person officially overweight or obese by raising his BMI.

For both sexes, Cawley and Meyerhoefer say, "the large average effects of obesity…are explained by relatively few individuals with very high BMI that incur very high medical expenditures." This pattern, which is similar to what Finkelstein has found, suggests that the merely portly and even the mildly obese should not be blamed for racking up outrageously high medical bills, because they don't. The vast majority of people who fail to heed the government's BMI recommendations apparently are not contributing much to obesity-related health care spending.

What about the folks "with very high BMI"? I would say insurers should be free to charge them higher premiums, although the logic of ObamaCare's ban on discrimination against people with "pre-existing conditions" suggests otherwise. Shouldn't insurers be forced to charge obese people the same rates as thinner policyholders, especially given the "strong genetic component to weight"? Not quite, it turns out. Reuters notes that the Patient Protection and Affordable Care Act "allows employers to charge obese workers 30 percent to 50 percent more for health insurance if they decline to participate in a qualified wellness program," although that does not necessarily mean they will lose any weight.

As for the government's share of obesity-related medical costs, this study does not address the question of whether obesity imposes a net burden on taxpayers. "We have data on BMI and medical care costs for only a single interval of time for each respondent," Cawley and Meyerhoefer write. "Ideally we would have longitudinal data that would allow us to examine the life cycle impacts of obesity, including early mortality (the costs of which are presumably mainly internal to the household)." Early mortality, by reducing spending on Social Security and Medicare, would mitigate the fiscal impact of obesity. Such effects seem to make smoking a net money saver for taxpayers. Citing Eric Finkelstein, Reuters says obese people do not die early enough to make up for their extra yearly medical expenses. Yet a 2008 Dutch study published in PLoS Medicine found that eliminating obesity would increase total health care spending in the long run, and that does not take into account increased spending on old-age benefits such as Social Security. 

But even if Finkelstein is right, we should be wary about agreeing that the net public burden he attributes to obesity justifies a government interest in what we eat and how much exercise we get. Forcing taxpayers to subsidize other people's medical care inevitably means forcing them to subsidize other people's risky lifestyles. Just as inevitably, people will cite that reality to justify increasingly intrusive policies aimed at discouraging such lifestyles. To me, that's an additional argument against forcing taxpayers to subsidize other people's medical care, which only encourages the totalizing ambitions of public-health paternalism.

For more about the War on Fat, see my 2004 Reason cover story.

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80 responses to “Is Your Flab Imposing a Burden on Society?

  1. FLAB!

  2. if u cant see ur junk w/o a mirror, u are teh [FATZ]

    1. Or you just have a big schlong. Something I’m sure you’re not familiar with Orrin.

      1. Or maybe it’s been inserted into something.

  3. I cannot stand this argument–your actions could cost society money; therefore, you’re society’s slave.

    1. I’ll make it simpler for you, ProL: you’re society’s slave. That’s what these people think, it’s just at this point they don’t quite have the power to enforce it so they come up with bullshit arguments. For now.

      1. Slavery: It’s a gas.

    2. It should not be forgotten that the Soviet Constitution is considered not as a cluster of duties imposed upon the State by the people, but as a generous gift presented to the people by the State.

      — from Soviet Law in Theory and Practice (1983)

    3. The TSA is a perfect example – we aren’t citizens, we’re subjects.

      Slave might be too strong a word, but serf is not.

  4. They can come for my flab
    when I’m cold on a slab.

    1. They can take my spare tire
      Not until I expire.

      1. They can take all my lard
        When I’m cold, still, and hard.

    2. It is not your flab,
      It is not your spare tire,
      It belongs to the State,
      (As it flames on the pyre.)

  5. That picture is making me queasy.

    1. You misspelled horny.

      1. “Tumescent”

        1. “Turgid”

    2. Because you woke up next to it?

      1. You’d know, seeing it was you. Sorry I crept off like that, I, uh…had a meeting.

        1. Dude, that wasn’t me. That was my mom.

          1. Dude, how drunk were you? Because you were in on that action. You and your mom are now closer than ever, and I am proud to have been able to make that happen. Episiarch: bringing people together with incest.

            1. That picture is making me queasy.

              1. And we come full circle! Like you and your mom last night!

                1. What, did you make another mom-son couple do The Ouroboros for your depraved pleasure?

                  1. I told you to stop it last time. It isn’t right.

    3. Making you queasy? Making you queasy? Are you shitting me?!?!

      I just learned the reason Reason instituted registration was so that they could hack my computer and take my picture and post it on their website! And you think you’re queasy?!?!

  6. If only there was a way to make it so that someone being fat didn’t cost me extra money. If only…

  7. BMI is bullshit. I weigh the same as when I was an athlete in college, competing iternationally. I was given a BMI test by a woman who did two things. She asked me if I exercised and then had me hold a funny metal contraption soon to be added to the Museum of Questionable Medical Devices. She then told me I was obese.

    1. Of course my sport was Sumo wrestling.

    2. …had me hold a funny metal contraption soon to be added to the Museum of Questionable Medical Devices

      Of course you’d say that, you have the brain pan of a stagecoach tilter.

      1. I really want to visit that museum.

        1. Just watch Dead Ringers.

          1. Is that the one with Jeremy Irons or the one with Jeremy Irons?

            1. No, idiot. It’s the one with Jeremy Irons and Jeremy Irons.

              1. I always get those two mixed up.

              2. Are you sure? Because I thought it was Jeremy Irons and Jeremy Irons.

          2. There’s got to be a porn version of that with Ron Jeremy and Ron Jeremy. My wit fails me at an appropriate title.

      2. At least he doesn’t have the bedpan.

  8. Prepare yourself to see a lot more of the same if PelosiCare isn’t shot down.

  9. if the predisposition to obesity is really a predisposition to dislike physical exertion and eat large amounts of high-calorie, low-nutrient food

    I eagerly await the wails of anguish from the Fat Acceptance crowd. U mad, fatties?

    1. There has also been an emerging body of fat political and sociological studies, some with a fat activist agenda, developing within the academy. The American Popular Culture Association has an area in fat studies and regularly includes panels on the subject. In addition, student groups with a fat activist agenda have emerged in a number of colleges including Hampshire, Smith, and Antioch colleges. ‘Fat studies’ is available as a course to study at some colleges, similar to other minority studies such as transgender studies and African American studies.[38]

      I wish I was surprised by this.

      1. “Fat Studies”?!?

        HAHAHAHAHAHAHAHAHAHAHAHAHAHAHA

        1. At least it’s easy to do. Go outside, look around. You’ll see fat people, so I guess tsudiying them can’t take too much work. It’s not like they move fast.

          1. I need $100k in grant money to see whether they’re easier to bait with twinkies or nutty bars.

      2. Soon, it will be illegal to sell diet books, as those will be considered fatism.

        1. No, that would be silly. It’s actually called weightism.

      3. that’s what we need. One more major for the Occutards.

  10. It worries that people have to buy more gasoline to transport their bloated bodies, for instance, and it says the lower wages earned by obese women amount to “a $76 weekly obesity tax,” although these costs are borne by fat people themselves and therefore hardly count as externalities justifying government intervention.

    Since the collective owns you, your reduced productivity constitutes theft from the collective.

    Forcing taxpayers to subsidize other people’s medical care inevitably means forcing them to subsidize other people’s risky lifestyles.

    Our betters in government have to be seen as doing something about the problem, and if they had to create the problem in order to do so, so be it.

    1. “Forcing taxpayers”

      There’s the heart of the problem right there.

    2. Since the collective owns you, your reduced productivity constitutes theft from the collective.

      That’s all the need be said about all of these ‘externalities of your personal lifestyle’ studies.

      I remember back in the day some of my liberal friends never quite got it when I told them that Capitalism lets them be artists and sit on their ass all day, socialism doesn’t. Socialism requires you to start producing something for the collective. Now choose your preferred system.

  11. The story lumps together all sorts of obesity-related costs, without regard to who pays them or why.

    This is no accident. It’s all the same to them. We are The Collective. Truly, Ayn Rand nailed it in Anthem on the point about the word “I” ceasing to exist.

    1. We think you will live to regret such sentiments.

    2. Individuality is a dangerous mental disorder. You think you don’t like the mandatory fat camps? Wait ’til you see what they have in mind for you!

      1. Every day will be like an episode of The Biggest Loser I suppose.

        1. 6079 Smith W.! Yes, you! Bend lower, please! You can do better than that. You’re not trying. Lower, please! That’s better, comrade. Now stand at ease, the whole squad, and watch me.

          1. I’ve posted and back-linked to that so many times, I’ve lost count.

            1. I think I linked to it a couple of weeks ago. The reality of the news is requiring its appropriate-linkage so often, that it should just be postscripted at the end of each blogpost.

              Or at minimum, a statement that we’va always been at war with Afghanistan.

  12. Forcing taxpayers to subsidize other people’s medical care inevitably means forcing them to subsidize other people’s risky lifestyles. Just as inevitably, people will cite that reality to justify increasingly intrusive policies aimed at discouraging such lifestyles.

    Well fuck, activity is risky. When is the government going to put a stop to this risky behavior and start mandating a more sedentary lifestyle. I’m sick of paying ever higher premiums because people can’t sit still.

  13. The whole thing is really a quandary for the busybodies. On the one hand, the evil patriarchy makes victims fat, and all body types are eekwul, but on the other, fatties are a burden on teh society. What to do?

    1. Why, naturally, the solution is to write laws and regulations and guidelines and establish agencies and bureaucracies and enforcers that are pursuing completely contradictory ends.

      1. I wonder if there’s a Law buried somewhere in there.

    2. blame male gaze for unrealistic expectations?

    3. Outlaw being fat without a permit?

      1. shall vs. may issue states

        1. Sorry, comrade, you failed to demonstrate enough loyalty on May 1, your fat permit is revoked. Get on the train to the, uh, “weight loss” facility.

          1. Fortunately, you ALSO get to help with the world food shortage. It’s a win-win situation!

  14. Does anyone else find it odd that the lowest mortality rate isnt in the center of the defined “healthy” range.

    It seems like healthy would be something like 27-32 BMI for men.

    1. I guess that should be 25-30 actually.

      But same idea.

      As someone in the middle of that range, its good to know. Although, I would like to get it down to about 25.

      I would like a little less gut than Ive got.

      1. If you think about it from a cavewoman’s perspective, it makes more sense.

        Which is preferable, the guy who works about 1 hr per day to catch food, then has enough to sit around and eat all day and put on a bit of gut (and thus can provide plenty of food for his family too) or the guy who is lean and gaunt and has to hunt for 8 hours every day?

        1. Yeah, I’d be screwed in a place where food is not abundant all year with my 18.2 BMI.

          Maybe (since fat people are apparently the property of the whole country) we should trade all of the fat people here for some skinny people living in places where there is not so much food. The trick, though, is figuring out which of them are naturally thin and which are just starving and woudl balloon up once they got to the US.

          1. Nothing more treacherous than fat people hiding in skinny bodies?

          2. Please, Zeb, anyone who goes to your website can see your picture, you’re not fooling anyone. You weight-traitor.

            1. Zeb’s website is NSFW.

  15. The “wellness program” isn’t really meant to lower the weight or BMI of enrollees. The heightened premium is meant to punish people with high BMIs, and the wellness program is a sorting mechanism to pick out the fatties who “deserve it” from those trying to lose weight or with some sort of “glandular disorder.” Basically just a way to be judgmental about fat people but filter out people based on some perceived scale of waistline justice.

    Of course, the whole setup is ridiculous. Pretty much anybody who generates above average body fat probably has a natural insulin resistance. Fat cells are the least resistant to insulin, so while muscles of a non-resistant person are sucking up the glycogen from eating, the fat cells of a resistant person get packed with glycogen because the muscles resist the insulin. So technically, anybody who is really fat has a “glandular disorder” and their main problem is eating a diet that requires lots of insulin (meaning starches and carbs).

    But we continue trying to pick and choose the fatties who are lazy and gluttonous from those who are merely victims of some sort of “glandular” problem. Of course, being insulin resistant on a high-carb diet is going to rob you of energy and force you to eat more food to compensate for the lost energy. So the perverse thing is that although plenty of fat people are certainly overeating, this is partially a consequence of insulin resistance.

  16. Who the fuck sneaked into my bathroom with a camera???

  17. My first thought was “so that’s why he always wears the jacket…” Then I realized it was Jacob’s story.

  18. Wouldn’t ending agricultural subsidies have the biggest effect on trimming down the fatties?

    1. Actually xanex would probably do that the best but there’s that whole WOD thing.

  19. The whole BMI metric should be totally re-examined. They clearly are putting the line between “healty” and “overweight” way too low. There is also diversity among people, a healthy weight is also determined by one’s bone structure.

    For example, I am a perfectly healthy adult, but my BMI put me just into the “overweight” category. My brother, also perfectly healthy, is the same height as me but weights at least 50 pounds more, he just has a much more substantial frame. He is not any fatter than me, he just has bigger bones and the acompaning muscles.

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