Two years ago, the Cleveland Clinic stopped hiring smokers. It was one part of a “wellness initiative” that has won the renowned hospital — which President Obama recently visited — some very nice publicity. The clinic has a farmers’ market on its main campus and has offered smoking-cessation classes for the surrounding community. Refusing to hire smokers may be more hard-nosed than the other parts of the program. But given the social marginalization of smoking, the policy is hardly shocking. All in all, the wellness initiative seems to be a feel-good story.
Which is why it is so striking to talk to Delos M. Cosgrove, the heart surgeon who is the clinic’s chief executive, about the initiative. Cosgrove says that if it were up to him, if there weren’t legal issues, he would not only stop hiring smokers. He would also stop hiring obese people.
This extra weight has caused a sharp increase in chronic diseases, like diabetes, that are unusually costly. Other public-health scourges, like lung cancer, have tended to kill their victims quickly, which (in the most tragic possible way) holds down their long-term cost. Obesity is different. A recent article in Health Affairs estimated its annual cost to be $147 billion and growing. That translates into $1,250 per household, mostly in taxes and insurance premiums.
A natural response to this cost would be to say that the people imposing it on society should be required to pay it. Cosgrove mentioned to me an idea that some economists favor: charging higher health-insurance premiums to anyone with a certain body-mass index. Harsh? Yes. Fair? You can see the argument. And yet it turns out that the obese already do pay something resembling their fair share of medical costs, albeit in an indirect way. Overweight workers are paid less than similarly qualified, thinner colleagues, according to research by Jay Bhattacharya and M. Kate Bundorf of Stanford. The cause isn’t entirely clear. But the size of the wage difference is roughly similar to the size of the difference in their medical costs.
The solutions to these problems are beyond the control of any individual. They involve a different sort of responsibility: civic — even political — responsibility. They depend on the kind of collective action that helped cut smoking rates nearly in half. Anyone who smoked in an elementary-school hallway today would be thrown out of the building. But if you served an obesity-inducing, federally financed meal to a kindergartner, you would fit right in. Taxes on tobacco, meanwhile, have skyrocketed. A modest tax on sodas — one of the few proposals in the various health-reform bills aimed at health, rather than health care — has struggled to get through Congress.
Cosgrove’s would-be approach may have its problems. The obvious one is its severity. The more important one is probably its narrowness: not even one of the nation’s most prestigious hospitals can do much to reduce obesity. The government, however, can. And that is the great virtue of Cosgrove’s idea. He is acknowledging that any effort to attack obesity will inevitably involve making value judgments and even limiting people’s choices. Most of the time, the government has no business doing such things. But there is really no other way to cure an epidemic.
1- If it is OK to discriminate against people who smoke, then logically it might be OK to discriminate against people who never, ever exercise, or who eat 3 doughnuts a day. It does not logically follow that it is OK to discriminate against people based on their BMI, any more than it is not OK to discriminate against a person (for a job where they want non-smokers) on the basis of that person having yellow teeth and wheezing. Maybe they drink a lot of coffee and have a cold. If one wants to argue that it’s OK to judge people based on their personal behavior, then judge based on the behavior.
2- Studies have shows that shaming fat people just makes them eat more. Francesca realizes that shaming others is extremely tempting in all sorts of circumstances, and self-righteousness feels terrific (?), but as a matter of public policy we may as well stick with avenues that have not been proven not to work, eh?
3- Francesca is all for healthier government-funded school meals; regulations that would make fruits and vegetables and whole-grain, chemical-free food easily accessible and affordable for everyone; more, better school gym programs (though she asks that as long as we are at it, we eliminate humiliating practices like kiddy captains picking their own teams, or, as was the case for a friend of mine from Connecticut, a school requirement — this at a public high school– to take co-ed water polo); incentives to help people exercise, etc. Heck, tax cola if you want; no one needs cola. Knock yourself out, policy makers. But don’t presume to know anything about my health status or my lifestyle based only on my weight.