Health Care » Hubman's Hangout

Is my kid fat? Am I fat? How do I know?

Last year public health authorities in Massachusetts mandated that all public schools begin calculating body mass index, or BMI, for all 1st, 4th, 7th and 10th graders, with the result being provided to their parents. While I wholeheartedly agree that the obesity epidemic is a huge public health problem [there are data that suggests that the average Americans life expectancy may decline for the first time in modern history] , I’m not so sure about this approach.

For starters, it’s a misuse of BMI, which was popularized by a 1972 paper by Ancel Keys, though the equation dates to the 19th century. However, BMI was explicitly cited by Keys as being appropriate for population studies, and inappropriate for individual diagnosis. Yet that is exactly what it we’re using it for. All that BMI does is suggest that if you fall into the 25-30 range, you might be overweight and you might be at greater risk of certain diseases. There is nothing definitive or diagnostic about it.

Last week, we received the state-mandated notice from the school nurse informing us of Darling Boy’s BMI. As if we don’t have enough issues with healthy body image role models (if there even is such a thing!), now we’re formally labeling kids as overweight or obese in elementary school. And really, is there any parent out there who is getting this notice and saying “Wow, my kids overweight? I had no idea!”?

The cynical part of me thinks this is just another example of the government doing something to say “look at what we’re doing to combat the obesity epidemic”. There was an excellent column in The Boston Globe Magazine on Sunday that brought up 2 very good points. In order to be in public school, all 4th graders must have a physical exam, whether they play sports or not. So in theory, every 4th grader has already been seen by a pediatrician, who one would hope would say something to the parents if the child’s weight might be a concern. The other point of the article, and I’m paraphrasing, was “the public schools can’t thin the herd, the herd has to thin itself”. In other words, it’s a matter of personal responsibility, or in the case of kids, parental responsibility.

I struggle with my weight and have for many years. I’ve been as heavy as 225 lbs and as “light” as 185 lbs, in the past 2 yrs alone I’ve lost almost 20 lbs and have proceeded to put most of it right back on. Is this anyone’s fault except my own? Hell no.

Why do I want to loss weight?

Because my parents are overweight and have illnesses directly attributable to their weight and overall lack of fitness.

Because 3 of my 4 grandparents died of cardiovascular disease.

Because it’s my responsibility as a parent to demonstrate healthy eating habits to my kids.

Because I want to, for my own sake.

NOT because of some government program.

See the picture below? That was taken in Sept 2008 for an HNT, when I was around 185 lbs. It’s time to turn things around, I WILL get back to that weight. And when I do, I’ll show you. No more stealth abs for me!

A month or so ago I put up a quick post about health care with a list that I stole from another blog and commented at the end of the post that I might occasionally write about politics and current events. Consider yourself warned…

I’m a big fan of Gregg Easterbrook, who writes Tuesday Morning Quarterback on ESPN.com. His column is a mix of really smart football analysis and whatever misc topics are on his mind on any given week. If you look at the comments, there are often readers who chastise him for writing about anything other than football, but I actually like that about him. This week, one of those misc topics was health care reform [scroll about 1/2 way down the page if the rest of his column doesn't interest you and look for "Why not standard pricing?"]. Among other things, he had this to say:

Think about a radically different way to attain health care — in which most people carry only catastrophic-cost insurance, then pay other health costs themselves. No one can budget for a severe illness or injury; every family will always need insurance against catastrophic medical expense. Suppose insurance covered only catastrophes, and you paid the rest. You might think, “No way I am paying some doctor hundreds of dollars to set a broken arm.” But today a typical family’s health care policy that appears to cost the family $5,000 a year actually costs $15,000, it’s just that much of the money is hidden as employer’s costs — and thus, as higher wages the employer can’t pay. If you spent $5,000 a year for catastrophic coverage but earned an additional $10,000 a year, you could cover those strep-throat and broken-arm bills yourself, and probably come out ahead. Plus you’d have a keen incentive to comparison shop. Doctors could no longer loftily say, “We don’t discuss prices.”

Homeowner’s insurance is catastrophe insurance. It pays if the house burns down — the kind of thing no one can budget for. It doesn’t cover all costs of maintaining a home; you pay most ownership costs and you comparison shop. If homeowner’s insurance worked like American health insurance, it would not only pay for fires but also cover utility bills, replacing broken appliances, baseballs hit into the window and all the food, drink and paper towels that pass through the kitchen. Certainly, a company could offer an insurance product that covered absolutely every expense of living in a home. But such insurance would be phenomenally expensive and full of ultra-complex rules; the insurer would also acquire an incentive to dream up excuses to deny payment. Just like American health care insurance!

I really like this idea, but mainly for a reason that isn’t stated in his column- personal accountability. Right now, there is no incentive for Americans to eat right or to exercise. I’m going to use my father as an example. He’s 65 yrs old, retired, and has Medicare plus a supplemental insurance policy partly paid for by the company he retired from. He’s also about 40 lbs overweight and has high cholesterol and high blood pressure.

What does the insurance industry do to encourage him to alter his lifestyle? Absolutely nothing. He continues to get his medication, we all pay a little more because of it, and he goes on failing to take care of himself.

Why not offer tiered pricing, tied to measureable improvements in health? Lose 10 lbs, your copay decreases by a certain amount. Or reduce your total cholesterol by 20 pts, we’ll reduce your out-of-pocket cost for your medication. While in the short term this will increase the insurance companies costs, the long-term goal is to encourage the individual to make the lifestyle changes that will enable to get off the prescription medication entirely, leading to long-term savings. Believe it or not, a prescription for blood pressure or cholesterol medication does not need to be a life sentence!

So imagine if we all only had catastrophic health insurance. How much cost savings would be possible and how much of an incentive would there be to take better care of ourselves?

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Before anyone jumps on me, I recognize that health care reform is enormously complex and what I say above is pretty simplistic in the grand scheme of things. I think that eliminating insurance companies ability to deny coverage for pre-existing conditions is absolutely essential, as is requiring standard pricing for services. Why should doctors be able to charge insurance companies less than an individual without insurance for an MRI, for example? If they routinely charge the insurance company less, it’s because they can afford to and still make a profit. Which means the individual without insurance is being gouged.

There is a model for health care reform that seems to have worked well. The Netherlands reformed their system in the last decade or so, with good success. Check out this article in The New Republic for some details.

Here is another plan that I’m a fan of:

exercise2