Obesity: America’s Self-inflicted Preexisting Condition
Consuming too many potato latkes and Christmas cookies has left its mark on our waistlines. Unfortunately for Americans and their medical care, the seasonal overeating seems to last all year. Indeed, the American Medical Association has declared that obesity is a disease.
It may be more accurate to describe obesity as a contributor to certain diseases. Obesity raises the risk of premature death, heart disease, high blood pressure, stroke, type 2 diabetes, gallbladder disease, breathing problems, certain cancers, and osteoarthritis. Certainly, obesity can result from certain uncommon diseases and hereditary factors, but most people become obese simply because they eat too many unhealthy foods and do not exercise.
At its last count, the Centers for Disease Control and Prevention (CDC) estimated that 40 percent of U.S. adults age 20 and over, 21 percent of teens, and 14 percent of preschoolers are obese. A December 2019 study that analyzed 26 years of body mass index (BMI [the relation of weight to height]) data concluded that half of U.S. adults will be obese (BMI>25) by 2030. Some 25 percent will be severely obese (BMI>35). Moreover, less than 5 percent of adults get the recommended 30 minutes a day of physical activity. And even when people living in “food deserts” were presented with healthy options, only 10 percent changed their evil eating ways.
According to the CDC’s last comprehensive analysis, the annual medical cost of obesity in the United States to Medicare, Medicaid, and private insurers was $147 billion in 2008. And the medical costs for obese people were $1,429 higher than those of healthier weights.
The saddest development is the cultural normalization of obesity with lingerie models, singers, and television shows celebrating fatness. Do we high-five people with other lifestyle related conditions such as alcoholism, emphysema, or coronary artery disease? Of course not.
The obese are easy targets for drug company peddlers of quick fixes or “providers” who want to extract money from third-party payors. U.S. pharmaceutical companies spent $6.1 billion on direct-to-consumer prescription drug advertising in 2017. Many ads feature chunky type 2 diabetics happily frolicking about, thanks to the drug company’s magic pill. The ads might as well say, “pass the chocolate cupcakes with statin sprinkles drizzled with insulin.” We all know the prescription of eating less and exercising more is free of charge.
Alas, we are losing the battle of the bulge. A recent study found that participants failed to lose weight despite reporting that they were exercising and watching their diet. The authors concluded that “many of [the participants] might not have actually implemented weight loss strategies or applied a minimal level of effort, which yielded unsatisfactory results.”
While politicians debate the merits of spending trillions of dollars on government-sponsored medical care, a correctable source of high medical costs is hiding in plain sight. Irrespective of who pays for medical care, rational economic decisions must be made. The Affordable Care Act (ACA) waved a magic wand and removed preexisting conditions from the underwriting equation when calculating premiums. A sick person and a healthy person of the same age could purchase insurance at the same price. Consequently, the ACA doubled the costs for people who made the effort to take care of themselves.
The ACA did allow a “tobacco surcharge” of up to 50 percent more for premiums. Why not an obesity surcharge? This would provide an incentive for consumers to take obesity seriously. Additionally, health-conscious persons would not have to pay for the bad habits of others through taxes to fund government health insurance programs or through higher private insurance premiums.
Those who are stricken with illnesses through no fault of their own need a path to affordable medical care. A good start for lowering costs would be eliminating costly middlemen by encouraging consumers to pay directly for day-to-day medical expenses. Expanding contribution limits and eligible uses of Health Savings Accounts would help pay for the more reasonably priced direct-pay surgery and other alternatives to insurance like direct primary care.
With regard to insurance, we need a revival of competition in the insurance market with multiple products and carriers. Once again, single men could opt to decline pregnancy coverage. We need to restore the pre-ACA availability of low-cost catastrophic (major medical) insurance policies to all ages. Even before mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the large majority of insurers offered guaranteed renewable policies. Here, assuming timely payment of premiums, at the end of the policy period the insurer must renew coverage regardless of the health of the insured. Naturally, this valuable feature costs more but provides consumers with a strong incentive not let the insurance lapse.
Let’s confront the elephant in the room. Healthcare policy should promote personal responsibility, rather than encourage free riders. In America we are free to overeat and under-exercise but we have no right to make innocent bystanders pay for the consequences.
Patients and Physicians Unite: You Have Nothing to Lose but Your Chains
By Marilyn M. Singleton, M.D., J.D
In an entertainment venue called the “Escape Room,” participants are locked inside a themed adventure room, and they must figure out how to escape. Themes include prisons, KGB interrogation, and hostage situations. Perhaps a new theme could be ObamaCare.
Despite a large majority of Americans reporting healthcare as their number one concern, Congress does not have the political appetite for a serious assessment of the Affordable Care Act. It’s time for Congress to say, “ACA and its ‘fixes’ are not working; cut our losses and move in a different direction.” New proposals should focus on reducing the cost of pharmaceuticals and medical services rather than shifting costs from one entity to another via mandated insurance benefits and government subsidies.
Dear Congress, please act on a few simple reforms that will help everyone and hurt no one—except the drug lobbies and middlemen.
First, seniors must demand to be treated like thinking adults—and save the federal government money in the process. Under current law, anyone age 65 and over who is entitled to Social Security benefits is automatically entitled to “free” Medicare Part A (hospital coverage). But if a senior wants to decline Part A and seek or keep other medical care options he must forfeit his Social Security benefits. As Judge Rosemary Collyer noted in a legal challenge to this rule, “plaintiffs are trapped in a government program intended for their benefit. . . They disagree and wish to escape.” Alas, the 1993 regulation was interpreted to confirm the draconian punishment for wanting to break free of the government control. To right this wrong, will one brave congressperson or senator revive the Retirement Freedom Act and support the Medicare Patient Empowerment Act that makes it easier for patients and physicians to opt out of Medicare?
Second, seven of ten Americans use prescription drugs, and they overpay for these 23 percent of the time. Patients often aren’t told they could pay less by not using insurance. If the insurance co-pay is higher than the actual cost of the drug, the middlemen (pharmacy benefit managers) keep the difference.
Legislative remedies exist. The bipartisan Patient Right to Know Drug Prices Act prohibits health insurance issuers and group health plans from restricting or penalizing pharmacies who tell enrollees the differential between a drug’s cash price and the insurance plan’s cost. The bipartisan Know the Lowest Price Act of 2018 prohibits health plans and pharmacy benefit managers in the Medicare Advantage program from restricting pharmacies from informing individuals regarding the prices for certain drugs. The bipartisan Transparent Health Pricing Act requires entities that furnish health-related products or services to the public to disclose the wholesale, retail, and discounted prices for those products and services at the point of purchase and on the Internet.
And when the price of brand name drugs has increased 10 times more than inflation, dear Congresspersons, consider supporting the Competitive DRUGS Act prohibiting name brand drug companies from compensating generic drug companies to delay a generic drug’s entry into the market.
With regard to medical services, the Direct Primary Care (DPC) model is burgeoning as patients yearn for quality time with their doctor at an affordable price. Here, all primary care services and access to basic commonly used drugs at wholesale prices are included in a fixed transparent price. Congress should support the Primary Care Enhancement Act, a one-page bill that allows Health Savings Accounts (HSAs) to be used to pay enrollment fees for DPC practices. Many Medicare beneficiaries prefer this model as they remember the era when patients actually knew their doctors.
Moreover, the DPC model saves federal dollars. Prescription drugs accounted for $110 billion in Medicare spending in 2015, 17% of all Medicare spending. With DPC dispensing, the cost of pharmaceuticals can be as much as 15 times lower than pharmacy prices. And Medicare spent $17 billion on potentially avoidable hospital readmissions. DPC’s better coordination of chronic care decreases hospital admissions.
Numerous bills designed to give patients more control over their medical care include provisions that: increase the maximum HSA contribution; allow Medicare eligible individuals to contribute to HSAs; allow members of healthcare sharing ministries to participate in HSAs; and allow individuals who participate in DPC practice, or who receive care from an employer’s onsite medical clinic to participate in HSAs.
Physicians want freedom to do the best for their patients and patients want good care at affordable prices. Will Congress act or continue to let such liberating legislative opportunities wither away?
Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).
Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.
While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.
Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.
Soporifics and Soullessness
By Marilyn M. Singleton, M.D., J.D.
Have we lost our collective minds? A mass shooting with no readily apparent motive is an extreme representation of our sense that our social fabric is unraveling. This is one of those things that people don’t believe can happen until it happens. And despite the unspeakable tragedy, it took less than an hour for politicians to criticize the President ghoulishly exhorting that we need more than prayers and consolation. Maybe we do, but at least give the circle of victims a chance to deal with their personal grief before spouting off. At least CBS had the decency to fire its soulless vice president and senior counsel Hayley Geftman-Gold after she posted “I’m actually not even sympathetic bc [sic] country music fans often are Republican gun toters [sic].”
We have become a culture where Tim Tebow is mocked for kneeling in prayer before a football game while others are praised for “taking a knee” during the National Anthem—which by the way is not praying. Taking a knee in American football is when the quarterback drops to one knee immediately after receiving the snap, thus automatically ending the play. Taking a knee is a boring but effective move by the winning team toward the end of the game, as it does not allow the opponent the opportunity to regain possession of the ball. In urban lingo it means to take a temporary break from an activity.
Clearly, “taking a knee” is not praising a Higher Power that many on this earth believe in. And standing for the Anthem does not make one a racist. Note to partisan “news” presenters: when you push a pendulum on one direction really hard, when released it swings the other way with equal or greater force.
Living in virtual reality is no longer beyond the fringe. Children are becoming obese because they are participating in sports through video games rather than actually tossing around a ball to one another.
What happened to talking to each other? You don’t need a psychology professor to tell you that smart phones increase loneliness. Just walk down the street and you’ll see far too many couples walking, each with their own cell phone, obviously not talking to each other. Texting a few abbreviated words has replaced real conversation and emotional connection.
And we wonder why opiate use has risen to epidemic levels. People have always had their troubles. And man’s desire to avoid suffering whether physical or emotional, whether through alcohol, opium, mushrooms, or coca leaves has been documented for at least 9,000 years. But now the public has been convinced they can’t just be “high on life” and learn to cope. Big Pharma’s direct-to-consumer television ads quietly list innumerable side effects while extolling the virtues of their wares and the consumer’s inability to live without them.
Nearly 70 percent of Americans take at least one prescription drug. The statistics from the Rochester Epidemiology Project in Olmsted County, Minnesota (which are comparable to those elsewhere in the United States) reveal that the top three medications consumed are antibiotics (17%), antidepressants (13%), and opioids (11%). Antidepressants and opioids were the most commonly prescribed among young and middle-aged adults.
As physicians we do not want to become numb to patients’ needs while being consumed by government dictates. Electronic medical records should not become the excuse for hiding behind a computer screen—particularly with members of the younger generation who came out of the womb with a cell phone strapped to their ear by the umbilical cord. We need to be free to spend precious time getting to know our patients. Medications have saved countless lives, but prescriptions cannot become the tool to move along the overbooked office schedule or a quick fix to placate the demanding patient.
Let’s take heart. When left to our own devices and stripped of artificial political labels, we humans rise. Just ask our first responders and medical personnel or the hurricane volunteers or the victims helping victims or the thousands of people donating blood or the over 30,000 donors to the Go Fund Me page for the Las Vegas victims.
United we stand.
Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).
Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.
While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.
Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.