On a recent pleasure trip to San Francisco, I took a ride on one of the many historic streetcars that ply that city’s waterfront. Car 1058 is one of the kinds of cars that made up the fleets of such big-city transit agencies as Chicago’s CTA and the old St. Louis Public Service Co. I boarded the car because I wanted to learn more about public transit technology; I left it thinking about public health economics.
The car, you see, was built in 1948. While comfy enough, the seats were remarkably narrow compared to seats on today’s buses and transit trains. This I expected. There is at work in the U.S. a law of the conservation of calories. Fat may take on various forms, but the total amount of fat in the nation remains constant over time. Every pound that one person manages to sweat off, her neighbors eat on. So I knew riders used to be slimmer than riders are today, but only riders who were very much slimmer could have fit onto those seats.
Americans eat more food than their bodies need. I will leave aside for moment the vexed and largely misleading question of whether fatness is ordained or willed, whether it is an addiction or a weakness, an illness or a condition, a problem of too strong genes or too weak will. I expect that extreme overweight will someday be shown to have medical as well as social and psychological causes, such as a genetic adaptation in babies born to mothers who starved them in utero.
However, my interest here is not the private causes of the obesity trend but the public effects. Helping healthy people stay that way is hugely cheaper than curing them when they are not, but the latter is the priority of medicine as practiced in the U.S., with ruinous effects on the fiscal health of both our public and private sectors. It was last year, I think, that I read in the SJ-R that the two Springfield hospitals were seeing more and more patients who were grossly overweight. Thirteen percent of Memorial’s in-patients for example, weighed more than 250 pounds at admission in 2009 and four percent weighed more than 300 pounds. Moving that much patient requires special lifts and beds, trained personnel and strengthened and widened mattresses, wheelchairs, walkers and toilets. Even chairs in the waiting rooms have been made wider.
Until very recently, people who got sick obligingly died sooner than did healthy people, thus relieving their families (and later their insurance groups and their township, state and national governments) of the cost of caring for them. A smoker who racked up huge bills for the treatment of emphysema and cancers usually died years before the equivalent nonsmoker, enough sooner in fact that the lifetime cost to whomever insured his care was less than average.
The problem is that medicine – which in the U.S. is more clever than wise – has gotten better at keeping even very sick people alive. And the very fat tend to be very sick late in life. Being grossly overweight does not make people die young. Rather, it tends to blight their later years with all kinds of debilitating conditions such as diabetes that are as expensive to treat as they are unpleasant to endure. As a result, fat people rack up annual medical bills some 42 percent higher than those of normal-weight people.
Analyzing Medicare data, federal researchers in 2003 found that elderly people in good shape at age 70 could expect to live a further 14 years, during which time they racked up cumulative health care bills averaging $136,000. Less healthy 70-year-olds lived only 11 more years, but although they lived shorter lives they racked up bigger medical bills along the way, amounting to $145,000.
That difference (about seven percent) is not staggeringly large, but since 2003 sick people are living longer and longer, and there are more of them. According to a 2010 report by the National Bureau of Economic Research, obesity accounted for 17 percent of all U.S. medical costs in recent years, or nearly $170 billion per year. Other analyses estimate that, of the expected increase in annual Medicare expenditures of about $360 billion between 2008 and 2018, nearly $265 billion will owe to obesity-related health care costs.
The figures suggest that the seminal issue before health care reformers is not public v. private or single-payer v. vouchers. It is how to transform a system of medicine that pays doctors and hospitals to keep sick people alive into one capable of helping healthy people to not get sick.
Contact James Krohe Jr. at firstname.lastname@example.org.