• The blame du jour

    This post has been cited in the 16 September 2010 edition of Health Wonk Review.

    Let’s start with this:

    That’s the cost, per person, for health care in eight of the ten richest countries in the world.  That’s per person.  In other words, that includes all the people with no insurance, all the people who have no access to the system.  And still, we spend about two to three times what all these other countries spend per person on health care.

    When confronted with numbers like these, people feel a need to find a reason.  They need something to blame.  And no one ever wants to blame the system.  So we blame it on something else.  The blame du jour seems to be the obese.

    The CBO just released a new report on obesity.  Jacob Goldstein comments:

    We know that obesity contributes to health-care costs at the population level. Obese people tend to have higher rates of a wide range of diseases than people who maintain a healthy weight; as the percentage of Americans who are obese has increased, so has the disease burden.

    Now, a new report from the CBO points to a related phenomenon that looks like a pretty big deal: The extra health costs for each obese person have skyrocketed in the past few decades.

    Back in the late ’80s, per capita health-care spending for obese adults was about 8 percent higher than spending for adults of normal weight; in 2007, health-care spending for each obese adult was about 38 percent higher than spending for each normal weight adult.

    I don’t want to minimize obesity, OK?  It’s a huge problem and I have covered it before.  Don’t walk away from here thinking I’m saying anything else.

    But it’s not the cause of our health care cost problems.

    Check this out.  It’s from a McKinsey & Company study, Accounting for the cost of health care in the United States:

    What they did is figure out the relative prevalence of 134 disease states between the US and six other countries (Japan, Germany, France, Italy, UK, and Spain).  They also figured out how expensive these disease states were to treat.  Knowing the relative costs, and the relative prevalences, they determined how much more we could expect to spend compared to other countries because of the prevalences of disease.

    Let me orient you.  Diseases which are more prevalent in the US relative to other countries are shown by points near the top.  See Obesity there?  It’s high, because we’re very obese.  However, diseases that are more expensive to treat are towards the right.  So, Multiple Myeloma is less common in the US and expensive.  That should help out our overall costs.  Hepatitis B is also much rarer in the US.  But it’s not nearly as expensive to treat, so it doesn’t help us out much.

    Obesity isn’t that expensive, either.  It’s not driving our costs.

    Before you start in on me about how obesity is linked to other things and such, you should know that the overall McKinsey & Company analysis showed that the prevalences of disease in the US could account for perhaps an extra $25 billion in health care spending.  Let me make a new chart for you:

    Yes, obesity is more prevalent in the US, and yes, caring for it costs real money.  But even if we get obesity down to the levels in other countries, it’s not going to magically erase the problem.  We are spending two to three times per person what they are.  There is no simple fix here.  There is no one, and no thing, we can easily blame.

    • “I don’t want to minimize obesity, OK? It’s a huge problem… ”

    • Bob,

      I wish I could say I did that on purpose.

    • We have one of the lowest smoking prevalence rates in the world (canada’s is lower, i think); people forget this when putting forth the cheeseburger hypothesis. It is mostly prices, with utilization and health effects being real but smaller drivers of spending differences.

    • I suspect we miss some of the costs associated with obesity, but I think you are largely correct here.


    • How did the study control for the problem of obesity expressing itself as other diseases – e. g. diabetes, high blood pressure, various joint failures, strokes?

      Before we partially absolve obesity, can we be sure the study protocol did not simply fragment the identity of obesity into it’s multiple pathological expressions?
      Indeed did the study have any other choice?

    • As an obese and metabolically healthy 57 year old (by which I mean, all of my test numbers are ones that my thinner colleagues would love to have, including blood pressure, blood sugar, lipids, HDL and LDL cholesterol, kidney function, liver function, echocardiogram, electrocardiogram, thyroid, Vitamin D, and anything else they can think to test me for — all of which are not only “okay” but nearly perfect … I’m genetically blessed I guess), I can readily attest to the fact that my employer-provided HMO deems it necessary to perform TONS of “extra” tests (and offer “extra” medical services) which I neither need nor want, and which they do not insist on giving to my thinner co-workers of the same age.

      In fact when I was first assigned to my current doctor, in my very first visit (before she’d even examined me or cracked open my chart) I got into an extended argument with her because she kept insisting on trying to convince me to sign up for bariatric surgery. After telling her that I neither needed nor wanted bariatric surgery, I finally said, “LOOK, my health insurance plan explicitly excludes any kind of weight loss surgery for any reason, and I couldn’t afford it out of pocket even if I wanted it, so let’s talk about something else.” Think that was the end of it? Oh, no! She then launched into a long speech explaining to me that, “there are ways of getting around that,” and trying to convince me to go to a “seminar” (a.k.a. sales pitch) touting the benefits of bariatric surgery. She also wanted me to get a bone density scan, even though I happen to know that with NO risk factors (and in fact, with obesity being somewhat protective of bone density, as it turns out) I am too young to begin having routine bone density scans.

      My doctor (fresh out of med school) seems so convinced that everybody who is obese is on death’s doorstep, that she just can NOT imagine that maybe, MAYBE, I’m really not about to croak. She seems to keep wanting to do more and more tests to try to find something horribly wrong that is on the verge of killing me.

      If 2/3 of the population is “overweight or obese” and THIS is how drs are going to be approaching that 2/3 of the population, it might eventually become a factor in increased health care costs. But I would argue that they shouldn’t be acting that way in the first place.

      • If your doctor says you are fat/obese, and you need surgery to cure fatness/obesity, then you might want to consider doing something about being fat/obese.

    • Another way of putting what I said above — in the USA, collectively, we are spending many, many billions (maybe even trillions by now) of dollars on “obesity prevention” efforts, and all that spending gets ascribed to the “cost of obesity.” Yet there is absolutely ZERO evidence that any of these “obesity prevention” efforts actually prevent even a single case of obesity — and mounting evidence that they don’t (for example, all the nannying of small children with school-based “obesity prevention” efforts which are often far too complicated for those small children to comprehend) doesn’t seem to change the “obesity rate” in schools or communities where it is practiced by one iota).

      These are not “costs of obesity.” They are “costs of obesity HYSTERIA.” (2 different things) Same with the 100’s of billions of dollars spent on various weight loss programs, products and services every year. The only one deemed “effective” in clinical trials was Weight Watchers, and the very definition of “effectiveness” is quite stretched, given that the average weight loss after one year of unlimited services was less than 7 lbs. A 7 lb weight loss does not change an obese person into a thin person unless perhaps that person started out at 27 lbs and lost 7 lbs to become only 20 lbs. But Weight Watchers doesn’t have a program for infants, so we can assume that was not the magnitude of the “effectiveness” of it..

    • That last pie chart is deceptive and/or confusing. Does the green part represent health care costs which aren’t explained by disease prevalence AND which are over the amount expected given GDP?

      I think it would be useful to see it as a percentage of “overspending” rather than a percentage of overall spending.

    • But what about taking into account the scale of the disease? A cheap disease that is widely prevalent can still cost a lot. And perhaps many of us are considering possible cascading health symptoms that leads to other diseases that might be listed as separate but in actuality are borne from obesity. If that’s not the case then yes, obesity probably isn’t too big a drain on healthcare.

    • The whole idea of this article seems to come from a study from McKinsey & Company who might have conflicts of interest based upon their undisclosed clients and they also seem to have gotten a few things wrong in the past http://en.wikipedia.org/wiki/McKinsey_%26_Company. I wouldn;t want to take their study as gospel without some supporting studies.

    • Devil’s Advocate here but if McKinsey & Company have undisclosed clients how do you know there is a conflict of interest?

      “And no one survived to tell the tale…”