USER FEE FUNDED UNIVERSAL HEALTHCARE Alan J Biloski At this writing, the House bill on healthcare reform Americas

s Affordable Health Choices Act HR3200 is 1,018 pages long while just the summary of the Senate proposal Americas Healthy Future Act of 2009 comes in at fully 223 pages.1,2 Despite the impressive length of these legislative efforts, both bills fail to capture the essence of the reform movement, creating a healthier America. Rather the foundation of each bill is built upon the concept of healthcare finance which seeks to balance new expenses with new revenues with better health as a byproduct. To be sure, some Americans currently without coverage would benefit from health insurance, but the magnitude of that benefit is overstated. In the Shattuck Lecture of 2007, Schroeder examined the contributions to morbidity and premature mortality and found that a mere 10% could be attributed to inadequate access to healthcare3.

By comparison, he found that fully 40% of health problems could be attributed to unhealthy behaviors, primarily smoking, obesity and alcohol abuse and that just these three adverse behaviors resulted in nearly 900,000 premature deaths annually. Schroeders findings are supported by a variety of other studies which demonstrate the widespread prevalence of unhealthy behavior among American adults. The 2000 Behavioral Risk Factor Surveillance System (BRFSS) survey of 153,805 respondents determined that only 3 % had all 4 healthy lifestyle characteristics (ie, nonsmoking, healthy weight, fruit and vegetable consumption, and leisure time physical activity).4 Virtually the same result is seen in a study restricted to healthcare professionals; the Nurses Health Study showed only 3.1 % of a large study group adhered to 5 healthy guidelines.5 The obvious solution to our healthcare impasse is to craft a program which penalizes bad behavior with taxes and fees- thereby incentivizing healthier outcomes - and uses the funds raised to

subsidize improved access to the uninsured. A key starting point is to stem the tide of obesity which has ramped from a plateau of ~13% of the adult population from 1960-1975 to ~34% in the most recent national survey with further growth projected.6,7,8

Far from being merely a cosmetic problem, obesity brings with it a host of serious health problems such as type 2 diabetes, hypertension, gallbladder disease, liver disease, coronary heart disease, cancer and reproductive disorders. Not surprisingly, obese people have healthcare costs which are ~42% higher than their healthy wealth counterparts, an annual bill which totals $147 billion.9 Of far greater import than the costs are the health consequences: a disease burden which results in a diminished quality of life plus years of foregone life expectancy. Since the linkage between rising rates of obesity and rising medical expenditure is undeniable, why shouldnt we price health insurance like auto insurance where bad behavior such as accidents or speeding tickets leads to higher premiums? Why dont we require annual height and weight measurements which trigger a deductible surcharge if the resulting BMI value exceeds 30, but which can be eliminated with sufficient weight loss? Bodybuilders with unusually high BMIs could be exempted upon the submission of a physician statement of a satisfactory skin fold test.

The census bureau estimates that there are ~48 million obese adults with private health insurance in the USA.10,11 I propose that we increase their annual deductable by $1,250 to both cover their added cost burden and to incentivize weight loss. Such a program could raise ~$60 billion or approximately 60% of the annual amount necessary to fund a universal health program in the USA. Critics undoubtedly will complain that the surcharge is excessive given the average nationwide health insurance deductable of ~$714 annually12, but the surcharge is less than the added costs of obesity (estimated at $1,429) 8 and the combined deductable of $1,964 is considerably less than the deductables which were actively debated for Californias universal health plan ($2,500-5,000).13,14 Others will claim that an obesity surcharge unfairly penalizes people for a genetic defect which they cannot control, but the epidemiology of monogenic and syndromic obesity is well known and has been shown to contribute to less than 5% of the observed prevalence.15 Polygenic mechanisms might make a substantial contribution to the balance but that seems highly unlikely given the large number of suspect genes (127) and their widespread distribution on every chromosome in the genome.16 A major role for polygenic obesity would therefore require the simultaneous evolution of multiple genes in tens of millions of living individuals over the time scale of years. Moreover, such a process must be occurring without detection and at a rate in America which is 2-to-3 times faster than other western countries. Such a selective and accelerated evolution seems improbable. Remarkably, our legal system seems to have arrived at the same skeptical view of obesity as a genetically determined disease since the Americans with Disability Act has established a safe harbor for such a health status measure in its 2008 Amendments: except in rare circumstances, obesity is not considered a disabling impairment predisposition to illness or disease is not an impairment.17 In fact, I would argue that the status quo is unfair since obesity is the only major adverse health behavior which is not taxed18,19.

To further dilute the issue of inequity, I propose that we simultaneously add surtaxes on tobacco ($1 increment on all forms cigars, cigarettes, pipe tobacco, snuff, etc) and alcohol (triple the existing federal excise tax of 5 per 12 oz beer, 4 per 5 oz wine, and 16 per 1.5 oz spirits) to spread the funding burden more evenly.

The result is a concise and accurately targeted healthcare plan which achieves the optimal outcomes of improved access for those who lack coverage and healthier behaviors among those segments of our population who have contributed most to the growth in health expenses. It also has important self financing elements (revenues and expenses move in parallel) since people who lose weight or reduce alcohol or tobacco consumption will also lessen their need for medical expenditures.

We also stand to gain longer term benefits in several areas. First, a legacy benefit to our children where the rate of obesity has more than tripled from ~5% of children and adolescents to over 15% since 1980.20 Since the body is not yet mature, the effects of obesity in children are more profound than in adults and include additional complications such as psychosocial, musculoskeletal and endocrine problems. Taken together, the impact of pediatric obesity may shorten life expectancy by 2 to 5 years midcentury, an effect equal to that of all cancers combined.21 A program which encourages parents and other influential adults to adopt healthier behavior towards diet and exercise can help reverse this trend. Second, we can protect another large segment of our population which is at risk of increased morbidity and mortality. In addition to the 34% of adults who are obese, another 33% are overweight and vulnerable to becoming obese. A program which increases awareness of the dangers of obesity and which includes economic penalties for obesity will help prevent the economic and medical consequences of additional weight gain.

Third, there is an international moral imperative to adopt this program. For the first time in history the number of overweight and obese people far exceed the number suffering from chronic hunger.22,23 Although diversion of crops to biofuels production has contributed to the hunger problem, any contribution to hunger from overfeeding is indefensible. As the developed country with the highest rates of obesity double or triple the rates seen in Canada and many countries of Europe the USA should set an example to aggressively reduce overconsumption among our citizens. Theoretical benefits must be realized in practice to have value, however, and many may be skeptical that the strong trends in obesity can be halted let alone reversed. Yet precedents for successful behavior change can be found in what were regarded as equally intractable problems. Seat belt usage has grown from 14% in 1983 to 81% in 2006; alcohol involvement in traffic fatalities has fallen from 60% in 1982 to 39% in 2004; and cigarette smoking among men and women has been reduced by half since 1960.24,25,26 Common to all of these developments were two factors: economic penalties and a change in societal attitudes. A surcharge on insurance deductibles for obese people can provide the appropriate economic penalty, but we must also reject the passive acceptance of obesity. Thanks to the widespread prevalence of obesity, advocacy groups such as the NAAFA (National Association to Advance Fat Acceptance) and the medias embrace of political correctness, any stigma of obesity has been replaced with a benign accommodation. For example, childrens clothing which previously maxed out at size 14 (husky or chubby) now is available up to size 20 with a typical label for girls of pretty plus. If we are going to change behavior we need to change attitudes and that can be accomplished in a constructive manner by highlighting the quantitative health risks, the shortened life expectancy and the adverse impact on our children of obesity.

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