Friday, August 11, 2006

Guest post by Skylanda: Fat - The new sin tax?

The idea of a "fat tax" - putting a tariff on high-calorie/low-nutritional value foods - is nothing new. Since the 1980s, self-appointed armchair health advocates and budget-wary politicians alike have suggest that forcing the price on fattening foods upward would help stem the rising tide of obesity. Basic economic theory suggests that if you put a higher price on undesirable items, people will tend to consume less of them; whether this approach actually leads to the secondary aim of reducing the average body weight remains to be seen.

Recently though, this reasonably well-intentioned idea has morphed into a push not for a tax on fattening foods, but a tariff on fat people themselves. After all - goes some twisted reasoning - if all these fat people are costing the health care system so much cash, they should have to take on their fair share of the financial burden. Once you hit a certain threshold, you gotta kick down the cash to cover the increased cost of your health care and other sundry services that you will surely suck out of society like a vampire bat at a bloody feast. Say, once you hit the 400-pound mark, you gotta dump an extra 10% of your earnings into the government pot. Sounds fair, right?

Not so fast. And definitely not so fair.

A simple calculation might tell you that more money from those who are draining the most out of the system would solve the problem - it would give incentive to lose weight, and it would add to the pool of public money we have to cover people's health care costs (especially Medicare, which kicks in around the age that obesity-related diseases take their greatest toll). But this simplistic model falls prey to a logical twist, a little something that public health wonks like to call the "prevention paradox." The prevention paradox posits that interventions that widely benefit society as a whole rarely offer profound benefit any one individual, who gets only a fractional improvement which, when added up over millions of people, has a profound impact. In other words, if everyone who falls into the arbitrary "obese" category lost ten pounds, that would have a profound impact on the national state of health - but that would not profoundly change the look of any one American, including the morbidly (or "malignantly") obese. As an offshoot of this, epidemiologists have noted that those whose risk factors are highest - in this case, the most obese, with the most co-morbid conditions - do not often comprise the demographic group who suck the most services out of a system. That is because there are usually very few people who belong to the extremely high risk group (say, in this case, those who weigh over 500 pounds), while millions and millions of people hover around the more middling weights (say, 200-250 on a five-eight frame), where risks for health complications from excessive weight are lower but not negligible. In other words, it matters very little what the few people people who weigh 500+ pounds use up in resources per capita; but it matters very much what the millions of us carrying just enough extra weight around use up in a knee surgery here and a couple decades of blood pressure medications there. And once you start talking in those numbers, you'll quickly find that the pool of people willing to cough up extra bucks for their own extra ten pounds drops through the floor, even though this is the group most likely to bust the health-care budget over the years.

But there's a more personal, individualized story too. Recently, after fifteen years of uncontrolled pain, a merciful neurologist evaluated my case and handed me a prescription. Within a few weeks, I went from a condition very aptly described as "chronic daily headache/mixed migraine type" to a couple of bad headaches a month with many pain-free days in between. I stopped buying ibuprofen in bulk orders and started going out of the house without double-checking my emergency drug supply to combat the headaches that barreled at me like an oncoming train wreck with no rhyme or reason. But the drug has some less than pleasant side effects, things like dry mouth, excessive sweating, and weight gain. Within a couple months, I regained the ten pounds I recently lost and put on another fifteen to boot; for the first time in my life, my weight started to push that arbitrary but ever-so-important border between "overweight" and "obese." (Please note that I'm far from an unusual case; just ask anyone who's been on the steroid drug prednisone, or any number of psychiatric drugs, for any length of time.)

So I have a choice. I can quit the medication and lose extra pounds. And if I do that, I will go back to having debilitating headaches that threaten my ability to finish graduate school. Or I can stay on the drug, finish graduate school, get my overeducated self into the productive workforce, and be content with that ever-progressing nudge over the BMI limit into the world of obesity. So do I "deserve" to be labelled obese, a burden on society, a drain on our precious public resources? After all, it's not my unchanged eating habits or my exercise regime, which had previously kept me in the lower ranges of the BMI; it's the drug, one might proclaim.

That remains to be an arguable question, but what does emerge from it is that this word "deserve" is a tricky one. It brings to mind connotations of old English Poor Laws - and that implicit (and often explicit) division between the "deserving poor" (women widowed with children, disabled war veterans) and "undeserving poor" (women with children out of wedlock, alcoholics, and the like). And that point so clearly underlines the crassly moralistic yardstick we descendants of the Puritans like to inflict on our fellow Americans, which is so apparent in this proposed "fat tax": if you are the deserving fat, you get some consideration of mercy; if you are the undeserving fat, you're not just on your own, you should be forced to pay for the wages of your gluttonous sins. Or maybe we should just throw all us fatties, from a BMI of 24.9 to a scale-busting 500+ pounds in the same category: we are all bad, bad, bad, undisciplined, lazy, gluttonous sloths (have I missed any relevant cardinal sins here?) who all deserve to be charged financially for gross negligence of our personal health.

The problem with this puritanical elitism (aside from the fact that there's no talk of charging wealthy people for high-risk recreational activities like downhill skiing and white-water kayaking) is that it solves none of the problems that push the trend toward sedentary lifestyles and the health problems that go along with them. It punishes without offering alternatives; it takes from those who are most likely to be experiencing weight-related disabilities and all it does in return is lend an air of self-righteousness to those who happen to have been born with the right genes, or blessed to have the pocket cash to pay for a gym membership, or lucky enough not to depend on a whole host of obesity-inducing medications. It does no service to tax the few extremes, unless satisfying a sanctimonious sort of fat lust could be considered in the best interests of the public's health.

Posted by Skylanda.