Struggling for common ground in the largest health crisis in America
Walking around Disneyland with my daughter the other night, I found myself face to face with one of our country’s most intractable taboos.
(Disneyland is still awesome for me, as a kid from 1970s LA. Truly magical.)
If you’re an observer of crowds, one of the more prominent features of the Disneyland crowd is how generally overweight our country has become (I live in the Bay area, and readily admit my interaction with folks on most days is not representative of a broad cross section of our population). I’d estimate at least a third of the folks at Disney are seeing Mike and Molly-level images in the mirror — and about 2–3% or so have more weight than they can carry around, and have therefore graduated to “mobility scooters.”
These industrial strength scooters have become commonplace at the Happiest Place on Earth. I’m guessing from the name that they were initially created for disabled and elderly folks, but clearly they’ve been reinforced for more rigorous duty. For every one of them we saw piloted by a fellow with a knee brace or an elderly grandmother, there were ten requisitioned for moving Big People around.
For a spell, I sat on a bench with my daughter and watched them wheel by.
I fell into reverie, thinking about how our policy choices have led to a predictable and avoidable epidemic, and how that epidemic mirrors many others in what is increasingly feeling like a gravely ill society. Our maddening melange of libertarian individualism, technological (and medical) savior-ism, American exceptionalism, and steroidal capitalism has delivered us a health care horror show — one with an endless appetite for cheap food, expensive medicine, and hollow self-delusion.
It strikes me nowhere can we identify how badly we need a new compact between business and society than right here on Disney’s Main Street USA. Libertarians and fanatical anti-regulation types love to claim that individual responsibility is paramount, and I suppose that means the growing percentage of obese people in our society are all at fault, and deserve the shame our culture heaps upon them. I tend to believe otherwise, that outcomes are driven by inputs, and right now, the inputs in our society are making us very, very sick.
Can we face up to this fact without dehumanizing or victimizing the people who now comprise more than a third of the US population? Is talking out loud about this issue even allowed? (I think I’m about to find out…)
It certainly feels taboo, because these are real human beings we’re talking about, and our society relentlessly shames overweight people as lacking will power and failing to conform to ideal body images projected in popular culture.
But come on, America’s obesity epidemic has been building for decades, and it’s only getting worse. When will we call it what it really is: A public health crisis, driven by outdated and dangerous policies around food subsidies and health care?
First and foremost amongst those failed policies is our society’s approach to food — how we grow it, how we market it, and certainly how we eat it. In short, we subsidize cheap calories — in particular sugar and corn syrup — and we’ve forsworn nutrition for convenience. Food companies, driven as all businesses are by profit and policy inputs, are literally rewarded for selling as much of their product to us as they can, regardless of the consequences. It feels an awful lot like our approach to energy — just as we’re hooked on cheap and environmentally damaging carbon-based fuels, we’ve built an entire economy on cheap and physically destructive food, and there are extraordinarily powerful forces at work insuring things stay that way.
(I should note that I actually do not lay blame at the feet of these forces — I believe they exist because we’ve created a system that requires them to act the way they do. The only way to change that is to change the rules of the system, not to reactively punish large corporations for doing what our society incentivizes them to do.)
Adding to the policy failure is our society’s approach to health care. Everyone seems to agree it’s a mess, but we have to think systemically if we’re going to fix it. Believe what you will about Obamacare, but they got one thing absolutely right: The new program instituted a historic shift from a reactive to a proactive stance. How? Through the economic lever of how payments were processed. The old government healthcare (and let’s not fool ourselves, the government is the single largest force in healthcare, period) paid set fees for service. This created a moral hazard in the market, as actors organized themselves around creating as many payment opportunities as possible. Need a knee replacement because you’re overweight? Check, there’s a fee for service. Knee replacement didn’t work, because you’re overweight and/or didn’t have proper follow up by your doctor? Check, we’ll do another one. Broke your hip because the second knee buckled? Check, there’s a third service to get paid for.
Obamacare is in the process of shifting government payments away from fee-for-service and toward outcomes — doctors and hospitals are paid a certain amount for a positive health outcome, and that’s that. No more triple knee surgeries — you get paid when the patient’s surgery is proven to have worked. There’s a set amount for that outcome, and that’s it. This kind of economic incentive drives markets to optimize for proactive health care — the kind that creates early detection of potential obesity, supplying nutrition education so the knee replacement is never needed in the first place.
It’s exactly this kind of thoughtful, informed policy we need right now if we’re going to solve our country’s obesity epidemic. And given the current administration, it’s highly unlikely we’ll see much of it coming out of Washington over the next four years. That means one thing: our country’s largest food and health care companies must get in front of this crisis, and lead. Whether or not they do, it’s abundantly clear is that our current crop of politicians will not. Meanwhile, our society is getting sicker, poorer, and more alienated. That’s not a recipe that’s good for anyone.