sin revenue

[nerdgirl 0]

By serendipity … or probably because your response had prompted be to pay more attention while I was listening to my iPod on the elliptical this morning -[at the irony] … there was a story on NPR “Obesity's Health Costs Grow Heavier: CDC” on the latest of what you accurately noted are many studies documenting the increasing annual cost of healthcare related to obesity.

On Monday , a new study was released (primary data) “Annual Medical Spending Attributable To Obesity: Payer- And Service-Specific Estimates,” which provides further data on the increasing annual cost of obesity related health care.

“Our overall estimates show that the annual medical burden of obesity has risen to almost 10 percent of all medical spending and could amount to $147 billion per year in 2008. Other studies have also quantified the extent to which obesity influences aggregate health spending. For example, Kenneth Thorpe and colleagues found that obesity was responsible for 27 percent of the rise in inflation-adjusted health spending between 1987 and 2001.

“We present nationally representative estimates of per capita and aggregate costs of obesity for all payers and separately for Medicare, Medicaid, and private insurers. We present these costs in total and separately for inpatient, noninpatient, and prescription drug spending--which was not possible at the time the previous papers were written. This additional detail helps specify the drivers of the costs of obesity. Our research shows that obese beneficiaries, on average, cost Medicare over $600 per beneficiary per year more compared to normal-weight beneficiaries. Finally, we estimate the extent to which rising prevalence of obesity is responsible for the increase in obesity costs that occurred between 1998 and 2006.”

The authors' results clearly show that healthcare costs associated with obesity are a significant contributor to increased annual costs.


They’re still looking at it as an annual cost and not taking into consideration earlier statistical death that avoid the long-term costs of caring for ‘healthy’ old people. I think they need to amortize over the expected lifetime. An even more sophisticated analysis would combine the Dutch researchers data with this new data looking at trends in obesity. At some point, if the percent obese population (w/associated earlier statistical death but lower overall cost) continues to increase will it, just by magnitude, cost more than “healthy” population (w/later statistical death but higher overall cost)? (Does that make sense?) When do the shorter term costs cost more than longer term costs or those that are only incurred if one lives long enough. I.e., where do the lines cross?


One of the main conclusions the authors main conclusions about which I have questions is:

“Across all payers, we estimate that had obesity prevalence remained at 1998 levels, spending attributable to obesity would have been $47 billion in 2006 rather than $86 billion (based on MEPS spending data). This implies that the rise in obesity prevalence accounted for 89 percent of the increase in obesity spending that occurred during this period.”

E.g., data in Figure 4.

It isn’t apparent to me in the methodology whether the authors accounted for the significant increases in spending per incident when they estimated the increased cost from 1998 to 2006. The earlier HA article noted that “70 percent of the rise in medical care spending between 1987 and 2000” was due to “rise in the cost per treated heart disease case.” Is that trend continuing and how is/was it factored into the more recent study? It does not appear that they factored in the increased cost per incident to get the 89% value. I emailed the corresponding author asking him. Will let you know what I hear back. Maybe they did account for it?

I did note one comment already on the HA site that speaks directly to policy:

“Reforming payment mechanisms to encourage clinicians to make more focused efforts to educate patients about obesity -- both prevention and treatment -- will be the first step. Unfortunately, Medicare and private payers would rather pay for bariatric surgery than for effective (time-consuming) management of nutritional and lifestyle changes. This effort makes ‘cutting the fat out’ a literal phrase in the process of reducing health care inflation.”

Does current policy prioritize “quick fix” treatment options (bariatric surgery) over other treatment options? That's what the MD comments suggest. Which costs more? Which has a higher profit margin for insurers? Which is more effective? (I don’t know.)

/Marg

Act as if everything you do matters, while laughing at yourself for thinking anything you do matters.
Tibetan Buddhist saying

[Ion01 2]

The typical excuse for taking our freedoms is that it is good for society. Well lets look at this really quick. Supply vs demand. If people don't get sick and need treatment then when they do the cost of that treatment will skyrocket. Also, past presidents have raised taxes on cigarettes numerous times claiming it will result in saving in healthcare costs. Guess what. It didn't!!!!
This is just another attempt to pay for the insane stimulus package and for the federal government to take more power!
If I want to be fat or kill myself with smoke or alchohol then that my decision....my life.... and i have to pay for the treatment so its my money and my treatment. If I don't pay then to bad for me! I should have been more responsible and prepared! As long as I am not screwing up anyone else why can't I screw myself up? I am healthy, I have never smoked or drank a drop of alchohol but if you want to kill yourself that way go ahead. Why should you not have that freedom as long as you are not kill me while your at it?
The real problem is what laws we have are not enforced. If you want to drink fine but don't get in a car and hit someone else or you should be punished....not have 5 previous DUI's and no insurance and hit my car and take 2 years to get my money from you and you still have a legal license and car? What is up with that. Do you think taxes will fix that? NO!!!

[cliffwhite 0]

[reply My parents have smoked for 30 years. Should they be covered?

If they've smoked for 30 years they've probably payed an awful lot of cigarette tax.
Yes , they should be covered,

Blues,
Cliff[

2muchTruth

[cliffwhite 0]

Quote

The real problem is what laws we have are not enforced. If you want to drink fine but don't get in a car and hit someone else or you should be punished....not have 5 previous DUI's and no insurance and hit my car and take 2 years to get my money from you and you still have a legal license and car? reply]

Why bring drinking into this? The charge should be wrecking. I don't care if the wreck was caused by a texter, a make up applier, someone who is reading while driving..etc. Wrecking is the offense imo.
As for a drunk driver vs. a sober driver who wreck, I'd support giving the drunk his license back first. He can sober up. The sober driver just doesn't drive well.

Blues,
Cliff

2muchTruth

• Quote

[Ion01 2]

It is simply an example of the current laws not being enforced. According to the law he should have lost his license before he hit me but he didn't even loose it after hitting me.

[cliffwhite 0]

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It is simply an example of the current laws not being enforced. According to the law he should have lost his license before he hit me but he didn't even loose it after hitting me.

Yeah, well you are right about enforcement. Cheney and Rumsfeld and countless CIA agents should be in jail for torture but the laws aren't enforced.

Blues,
Cliff

2muchTruth

[kelpdiver 2]

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Does current policy prioritize “quick fix” treatment options (bariatric surgery) over other treatment options? That's what the MD comments suggest. Which costs more? Which has a higher profit margin for insurers? Which is more effective? (I don’t know.)

/Marg

This is one reason I wondered about the Dutch study. Our system of care is geared towards critical care (surgery) which is quick but expensive, over long term health management which is time expensive.

The other difference *may* be in the nature of the obese. Having a little bit of weight isn't the worst thing for people that engage in a minimum level of physical activity. Europeans may be eating a bit richer food, but they're still walking and biking about. And anything based on BMI is going to capture a lot of fairly lean, if muscular, people as overweight.

In contrast, in America we've seen a rise in the morbidly obese. People who are very much overweight, and none of it is muscle. At least from what they keep printing in the news, that is been a big development over the past 20 years, and could account for a greater cost per incident. From what you wrote, seems like there is a conflict in the higher costs coming from that, or from more patients.

BTW, when it says inflation adjusted, is it using the overall inflation rate, or a more suitable health inflation rate? The rise in cost and availability of drugs for blood pressure and cholesterol alone is a pretty penny.

[happythoughts 0]

And then, there is the possibility of spawning the new industry.
Buying "thin credits" from skinny people to lower your
healthcare taxes. Cap-and-trade for calories.

Eventually, you arrive at the establishment of taxation
and laws that define what rights you have.
"You do not need ice cream or bbq to be happy.
If you wish to enjoy those foods, you must pay the tax to fund your additional healthcare costs."

It is already done in some states.
One state used to have a "luxury tax".
Kind of like a "happiness" tax, but phrased to appear
that it would not apply to you. Somehow, only "other people"
would have luxuries and "we" wouldn't have to pay it.
Guess what? It applies to the sale of tv sets.
Anybody still think that a tv is a "luxury item" ?
Nope, just a tax that is on the books. Once on the books,
they never go away...and, they eventually apply to everyone.

Calif bases license fees on vehicle cost, not road use (weight) like most states. That way, only "other people" with "luxury" cars will have to pay the extra tax. A light porshe is more than a heavier truck.

Greed, one of the seven deadly sins and your govt is
making money off of it by demanding a share.

[nerdgirl 0]

Quote

... in America we've seen a rise in the morbidly obese. People who are very much overweight, and none of it is muscle. At least from what they keep printing in the news, that is been a big development over the past 20 years, and could account for a greater cost per incident.

This past week I thought of this exchange and the idea of "sin" tax as I was looking for something healthy to eat in the Atlanta airport. It's one anecdotal example of when it costs more to eat healthy as opposed to other choices. So it's not a "healthy tax" perhaps counter-inducement from a financial perspective.

NB:I don’t think food choices are “sinful.” They’re just choices, and “sinful” food in moderation or occasionally can be blissful!

Thursday night my flight to DC got cancelled. Was rebooked on a later flight with no problem. (Kudos to Delta.) But I was going to miss my dinner date. (Will be back in DC in 10 days, already rescheduled. (I like those). $6.15 (0.38 lb). Just out of curiosity, I checked the prices at the Burger King, Chick-a-fil, Pizza Hut, and Cinnabon. One could get more food cheaper at the fast food vendors for less money. There also were a lot more people buying fast food. The market (people) clearly wants fast food.

I personally like a lot NYC’s requirement to disclose nutritional information at restaurants, fast food vendors, Starbucks (190 calories in non-fat medium carmel machiatto), etc. It’s hard to make a claim of not knowing.

Is that a good option? Should more localities make similar requirements? Not sure if there's been any effect in NYC, where people already walk more than most of the US.

/Marg

Act as if everything you do matters, while laughing at yourself for thinking anything you do matters.
Tibetan Buddhist saying

[riddler 0]

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What if people were to face the consequences of their actions for themselves? If they got lung cancer from smoking, they'd have to pay for the treatment (or buy a health plan that would). If they got fat, same story. That way, each person could decide for themselves if the cigarette, or the donut, was worth the true cost of their actions (including their future health costs). It'd be crazy, but that way we wouldn't have to police each other's actions, because we wouldn't have to pay the bills for them.

Great idea! I'm all for it (seriously, I would love to see this). Let's see, you've brought up several examples:

1. Smoking. Well, first you have to get all people with smoking-related illnesses to take responsibility for their own medical bills. According to the NCA, 438,000 deaths in the US alone are smoking related. Then, according to the ALA, the US has to foot the bill for about $100 billion in medical costs from smoking. So how many people are not paying for their actions? You've got to convince all of them to stop treatment for their life threatening illness, since they can't afford it. Then, there's the second-hand smoke issue, which is known to cause health problems in others. We don't even know how to measure that.

Maybe taxes are just the easiest way to recover revenue for this problem. We can also sue the tobacco makers, since they are delivering an addictive substance. We've done both. I would really prefer they take responsibility for their own addiction, as well as pay for any medical costs for second-hand smoke illnesses, but how do you plan to do that?


2. Obesity. $147 billion per year, with half of that paid for by Medicare and Medicaid, so at least $75 billion in socialized healthcare for overweight people. All we have to do is convince all those people to stop getting government assistance for their obesity. Maybe direct them to weight loss clinics, or better yet, put them all on treadmills that generate electric power for the rest of us.

There's no tax for obesity yet, but it'll come eventually. How do you plan to get all the fat people to start taking responsibility? We've already said that hospitals are required to treat people, regardless of insurance, so they can't be turned away. And we have substantial socialized programs for the elderly - should we take away their benefits as well?

Here's another example you didn't mention. My dad is 100% disabled (Vietnam), and he gets free healthcare. Much of that healthcare has nothing to do with his war-related injuries (heart problems, etc). Should we take away the veterans benefits that are not directly related to their war injuries?

Trapped on the surface of a sphere. XKCD

[rhaig 0]

not only that, but if the obese people refuse to turn around, think of all the starving children in the world who would love some soylent green.

let the smokers smoke themselves to death. But not where I can smell them. toss them in to the soylent green vat. but try to strip out the cancerous bits first.

--
Rob

[kelpdiver 2]

Quote

Ended up getting ~¾ cup of trail mix (dried cranberries, dried blueberries, hazelnuts, and peanuts) + ~1/8 cup (handful) of praline pecans (I like those). $6.15 (0.38 lb). Just out of curiosity, I checked the prices at the Burger King, Chick-a-fil, Pizza Hut, and Cinnabon. One could get more food cheaper at the fast food vendors for less money. There also were a lot more people buying fast food. The market (people) clearly wants fast food.

Overall, I think the people's wants are the key problem, but the result is that the alternatives aren't available until enough people want them, so it becomes self fulfilling in many places. I have a hard enough time in Southern California.

The occasional In N Out double burger, optional cheese, with no dressing and LTO (lettuce tomato onion) only isn't terrible. Though I've been told fairly explicitly to drop the O if I want to kiss that night. sheesh. It's the quantity that's gotten a bit out of whack. I think it was McDonald's that first found out they could up their profits with the value meal since labor and opportunity costs are much more than extra fries or a bigger fountain drink.

Quote

I personally like a lot NYC’s requirement to disclose nutritional information at restaurants, fast food vendors, Starbucks (190 calories in non-fat medium carmel machiatto), etc. It’s hard to make a claim of not knowing.

I worry a bit about the cost of this. SF and CA have debated it as well. Even if you exempt smaller businesses, does it discourage experimentation or specials because then you have to send a sample away for analysis? Or is it sufficient to take the average portion size and add the calories for the ingredients and publish that? Sounds like a minor lawsuit when someone relies on the 450cal that might range from 400-500. (see Seinfeld re: 'non fat' frozen yogurt)

Key is to know what ingredients are used at the very least.

[nerdgirl 0]

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The occasional In N Out double burger, optional cheese, with no dressing and LTO (lettuce tomato onion) only isn't terrible.

Concur, in principle. Good food & occasional indulgence is part of life, imo. Sometimes indulging _is_ fast food or comfort food.

Quote

It's the quantity that's gotten a bit out of whack.

Thought that there was an interesting parallel discussion in the cover story from this past weekend's NY Times Sunday magazine cover story: "Out of the Kitchen, Onto the Couch" on how industrialization of food has impacted the American diet. (Parts were a lil' too constructivist for my taste, but thought the there were some significant points nonetheless.)

Concluding lines:

"... how, in an ideal world, Americans might begin to undo the damage that the modern diet of industrially prepared food has done to our health.

'"Easy. You want Americans to eat less? I have the diet for you. It’s short, and it’s simple. Here’s my diet plan: Cook it yourself. That’s it. Eat anything you want — just as long as you’re willing to cook it yourself.'"

The thesis put forth is that it takes more time, sometimes a lot of time, to make much of the food that today can be purchased prepared from the grocery store.

/Marg

Act as if everything you do matters, while laughing at yourself for thinking anything you do matters.
Tibetan Buddhist saying

[kelpdiver 2]

Quote

'"Easy. You want Americans to eat less? I have the diet for you. It’s short, and it’s simple. Here’s my diet plan: Cook it yourself. That’s it. Eat anything you want — just as long as you’re willing to cook it yourself.'"

Half the Bay Area would starve.

But in my own experience, I found cooking often lead to larger portion sizes, not smaller. The constitution of the food might be better, but you can't bake one serving of lasagna. It's a bit easier cooking for 2 or a family, but for singles, there's definitely the time concern, but also the scale concern.

[TomAiello 26]

If you're interested, check out The End of Overeating. There's a Washington Post review of it here.

-- Tom Aiello

Tom@SnakeRiverBASE.com
SnakeRiverBASE.com

[nerdgirl 0]

Quote

If you're interested, check out The End of Overeating. There's a Washington Post review of it here.

Thanks - looks interesting to me!

Am curious about the science behind some of the assertions contained in the author's quotes and implied/inferred statements in the book review, as well as the policy implications. E.g.,

"Instead of satisfying hunger, the salt-fat-sugar combination will stimulate that diner's brain to crave more, Kessler said. For many, the come-on offered by Lay's Potato Chips -- 'Betcha can't eat just one' -- is scientifically accurate. And the food industry manipulates this neurological response, designing foods to induce people to eat more than they should or even want, [that implies it was intentional design on the part of the prepared food industry ... that's a harder case to prove than unintentional correlation or result of other independent factors, like cheaper cost of some ingrediants. Until one can show intentional motivation, I'm more inclined to attribute it to a combination of cheaper cost and dumb luck - nerdgirl] Kessler found.

"His theory [hypothesis seems more accurate based on the book review ... maybe he does show predictivity in the book - nerdgirl], born out in a growing body of scientific research, has implications not just for the increasing number of Americans struggling with obesity but for health providers and policymakers.

"Kessler ... sees parallels between the tobacco and food industries. Both are manipulating consumer behavior to sell products that can harm health, he said."

The review strongly suggests a neurochemical causation or attribution rather than a pure 'choice' issue:

"'Highly palatable' foods -- those containing fat, sugar and salt -- stimulate the brain to release dopamine, the neurotransmitter associated with the pleasure center, he found.

"In time, the brain gets wired so that dopamine pathways light up at the mere suggestion of the food, such as driving past a fast-food restaurant, and the urge to eat the food grows insistent. Once the food is eaten, the brain releases opioids, which bring emotional relief. Together, dopamine and opioids create a pathway that can activate every time a person is reminded about the particular food. This happens regardless of whether the person is hungry.

"Kessler estimates that about 15 percent of the population is not affected and says more research is needed to understand what makes them immune. "

He's suggesting medicalization of obesity, like one would not blame someone who came down with leukemia but instead treat it as a medical condition rather than result of normatively "bad" behavior. Whether I agree with the science (haven't looked at it) or not, not sure how useful that is for health policy.

/Marg

Act as if everything you do matters, while laughing at yourself for thinking anything you do matters.
Tibetan Buddhist saying

[kallend 2,148]

Quote

Quote

'"Easy. You want Americans to eat less? I have the diet for you. It’s short, and it’s simple. Here’s my diet plan: Cook it yourself. That’s it. Eat anything you want — just as long as you’re willing to cook it yourself.'"

Half the Bay Area would starve.

But in my own experience, I found cooking often lead to larger portion sizes, not smaller. The constitution of the food might be better, but you can't bake one serving of lasagna. It's a bit easier cooking for 2 or a family, but for singles, there's definitely the time concern, but also the scale concern.

Really? I find the reverse. Eating out nearly always results in bigger portions than I like, except in very expensive restaurants (there's a noticeable inverse relationship between serving size and restaurant quality, I've found). When I cook for myself I tend to make small meals.

...

The only sure way to survive a canopy collision is not to have one.

[kallend 2,148]

Quote

[that implies it was intentional design on the part of the prepared food industry ... that's a harder case to prove than unintentional correlation or result of other independent factors, like cheaper cost of some ingrediants. Until one can show intentional motivation, I'm more inclined to attribute it to a combination of cheaper cost and dumb luck - nerdgirl] /Marg

I think you underestimate the level of research activity by the mega food corporations. (Or maybe you misunderestimate it) However, I still think the bulk of the blame rests with the fat bastards themselves.

...

The only sure way to survive a canopy collision is not to have one.

[kelpdiver 2]

Quote

Really? I find the reverse. Eating out nearly always results in bigger portions than I like, except in very expensive restaurants (there's a noticeable inverse relationship between serving size and restaurant quality, I've found).

Yes, those restaurants dominate San Francisco. And with the recently mandated health insurance and sick leave for all, portions have shrunken a bit more in efforts to keep prices nearly stable.

There is a Claimjumper about 40 miles east of here. That must be the most disgusting restaurant on earth.

[TomAiello 26]

Quote

There is a Claimjumper about 40 miles east of here. That must be the most disgusting restaurant on earth.

Is that the one in Concord?

I love that place. Have you had their cream puff? It's the size of a football! Yum!

-- Tom Aiello

Tom@SnakeRiverBASE.com
SnakeRiverBASE.com

[kelpdiver 2]

Quote

Quote

There is a Claimjumper about 40 miles east of here. That must be the most disgusting restaurant on earth.

Is that the one in Concord?

I love that place. Have you had their cream puff? It's the size of a football! Yum!

Yep. when I was working at a company in Richmond filled with 20some year olds, that was their favorite place on earth.

Even their smallest dish, a chili burger, was the size of a small black hole of fat.

[tkhayes 348]

you already have to pay for their bills,

socialist or not, every country has fat people. you cannot legislate personal responsibility. It is a cultural decision that spans all of society. Japanese people are healthier because their diet is radically different from ours. No piece of legislation in either country actually spells that out.

Even if you burden 'people' with the 'cost of their actions', in the end if they cannot actually pay for it, YOU, and I end up footing the bill.

we will always have fat people, lazy people, sick people, poor people, unemployed people, and everyone else that you can find to blame societies problems on. we might 'tweak' the numbers over time, but you will never eliminate it.

we have fat people with health insurance (personal responsibility) and we have fat people without health insurance.

We have smokers with health insurance (personal responsibility) and we have smokers without health insurance

And we have white collared working class, decent wage earners with health insurance, and we have many without it.

So if I am in good physical condition and I do all the right things, and I work out and I have a job, and I don't smoke and I eat right and I still get sick? Where do I fall into your giant synopsis?

Does a smoker who is willing to play his cost of insurance not have the right to smoke?

[kelpdiver 2]

Quote

socialist or not, every country has fat people. you cannot legislate personal responsibility. It is a cultural decision that spans all of society. Japanese people are healthier because their diet is radically different from ours. No piece of legislation in either country actually spells that out.

Yet in the past 20 or 30 years, there was a radical shift in the number and severity of fat people in our country. It's unlikely that culture changed that dramatically (with one exception). There have been many changes driven by the government:

1) subsidies to corn making HFCS preferable to sugar.
2) funding and teaching mandates encouraging the elimination of PE in school
3) (maybe) regulations on employer health care don't easily allow for carrot/stick encouragement
4) Lousy vacation/labor policies have us working more than even the Japanese.
5) shifting of employment from manufacturing to desk work.

Biggest factor outside of government is
6) rise in home video game systems, leading to kids that play virtual sports instead of real ones. I don't blame Nintendo for this - I blame the parents.

1, 2, and 6 all seem highly significant and arose at similar times. The others are more of a failure to encourage healthier behavior.

[kallend 2,148]

Quote

Quote

socialist or not, every country has fat people. you cannot legislate personal responsibility. It is a cultural decision that spans all of society. Japanese people are healthier because their diet is radically different from ours. No piece of legislation in either country actually spells that out.

Yet in the past 20 or 30 years, there was a radical shift in the number and severity of fat people in our country. It's unlikely that culture changed that dramatically (with one exception). There have been many changes driven by the government:

1) subsidies to corn making HFCS preferable to sugar.
.

Graph of usage

However, HFCS has only 3/4 the calories/gram as sucrose.

...

The only sure way to survive a canopy collision is not to have one.

[kelpdiver 2]

nice graph. Got one for soybean consumption as well? That's increasingly used as filler calories in products.

The concern with HFCS seems to be about its glycemic index and other effects on appetite/metabolism, rather than just the calorie density.

Personally I just don't like the taste - I generally drink diet Coke now, but for regular, I find the difference in taste between sugar (Canada, sometimes Mexico) and corn syrup to be huge. I also look for lemonade and other drinks to use sugar, though there are more variables there to the quality of taste.