Punishing people for being unhealthy is certainly not a new concept. Everything from societal peer pressure and restrictions on things like where you can smoke, to calorie counts at fast food restaurants and financial hits through insurance have tried to convince people to just be healthier. And for some people, it may have worked.
But now the state of Arizona wants to take a similar "health initiative" and turn it into a money maker. Arizona's Medicaid program is cash-strapped, so now they want to tack on a fee to all those unhealthy people who are apparently sucking the system dry. Arizona is going so far as to single out groups of people whom they think are the biggest drain: folks who smoke or are obese. PWDs and others with chronic illnesses are also being included in this "fat fee," where they will be required to pay the fee if they don't follow their doctor's directions to lose weight (there's no indication that A1c or other measures of health would be included).
Some private insurance and state governments have already implemented a simple fine for people who are overweight or smoke, but Arizona's fee would be the first state-federal fine for low-income people.
There are so many problems with this initiative that it's hard to know where to start, but consider... why is it OK for the rich Arizonians to remain fat?! If it were so important for the state to use punishment to motivate behavior change, why wouldn't they charge the wealthy-unhealthy proportionately?
Since this is focused solely on low-income households on Medicaid, let's consider how much money goes into weight loss efforts: purchasing healthy, fresh, or possibly organic food (if you can get it where you live); exercise equipment and/or gym membership; clothing and appropriate shoes for exercise; and co-pays for medications and services (which are small compared with private insurance co-pays, but they still exist). Not to mention time: time off work, time meeting with doctors and nutritionists, time driving, time waiting in line at the pharmacy, and the complete lack of time with the physician that you're required by the law (if this AZ fee passes) to see.
Not to mention all the other factors you might not have control over, such as disability, race and genetic factors that contribute to prevalence in obesity (and diabetes). Talk about adding insult to injury!
A spokesperson for Arizona's Medicaid, Monica Coury, says "We want to stretch our dollars as far as we can. Part of that is engaging people to take better care of themselves."
Wha? Since when has punishment in the absence of rewards been proven an effective health engagement strategy? Since when does charging a $50 penalty do anything other than annoy people? Unless of course you are a 2-person family earning less than $15,000 per year, and possibly struggling to pay for your diabetes meds — in which case the fee becomes a large financial hardship.
We certainly agree that this country needs to address obesity and unhealthy lifestyle and eating behaviors. We're not shrugging our shoulders at that. But there are better and more productive ways to encourage healthy living that don't involve a fine! My suggestion: instead of charging people a nominal fee for not following directions, why not actually help prevent the reasons why 25% of Arizona's population is obese and 46% of them smoke? Perhaps gym memberships should be reimbursed? Perhaps there should be vouchers for healthy food?
Implementing programs that make it easier for people to be healthy is what would engage and encourage people, rather than sending them a "You're still too fat" bill every year. For diabetes in particular, some health insurers are trying incentive programs, like the one from UnitedHealthCare that provides discounted rates and no-cost office visits, lab tests, generic drugs, insulin, pen needles, syringes and lancets, as well as insulin pumps and supplies as long as members take certain proactive steps. They must "comply with diabetes and preventive care evidence-based guidelines" provided by the ADA. A tracking site collects information about the services members use, and has an automated reminder system to prompt them to get their checkups and lab tests regularly. Not a bad idea, it seems.
Meanwhile, we PWDs who are pretty engaged have been arguing with private insurance for years to pay up-front for the costs of staying healthy now, rather than waiting until serious complications set in that are vastly more expensive. Maybe instead of cutting gym class at schools or making fast food so appealing to children (Happy Meal toys anyone?), Arizona should cough up money for Weight Watchers programs and diabetes education, to name a few.
A "sin tax" does not count as helping!
I really liked the MSNBC op-ed in which contributor Dr. Art Caplan, professor of bioethics at University of Pennsylvania, writes: "And just to be fair, the governor can add the same tax to water-skiing, jet skiing, horseback riding, mountain biking, owning a swimming pool, paragliding, rock climbing, failing to wear a helmet while riding a motorcycle (Arizona has a very weak law) or choosing to work in roofing, mining or construction — or any other activity that carries a risk. Actually, if the governor really wants to make money, how about a tanning tax for those who bask in the Arizona sun and hike their risk of skin cancer?"
In addition to passing the Republican state legislature, this new bill would also need federal approval, because Medicaid is a federal program, so there's a good chance it won't pass. Still, if you live in Arizona, this is a great time to put on your Diabetes Advocate hat.
Finally, if this more about a state budget crisis than a health initiative (as seems to be the case), I'm sure we can all figure out ways to get the biggest bang for the buck that will actually ease the budget and help people be healthier. Right?