Berkeley, Calif.
TO listen to President Obama’s
speech on Wednesday night, or to just about anyone else in the health care
debate, you would think that the biggest problem with health care in America is
the system itself — perverse incentives, inefficiencies, unnecessary tests and
procedures, lack of competition, and greed.
No one disputes that the $2.3
trillion we devote to the health care industry is often spent unwisely, but the
fact that the United States spends twice as much per person as most European
countries on health care can be substantially explained, as a study released last month says, by our
being fatter. Even the most efficient health care system that the
administration could hope to devise would still confront a rising tide of
chronic disease linked to diet.
That’s why our success in bringing
health care costs under control ultimately depends on whether Washington can
summon the political will to take on and reform a second, even more powerful
industry: the food industry.
According to the Centers for
Disease Control and Prevention, three-quarters of health care
spending now goes to treat “preventable chronic diseases.” Not all of these
diseases are linked to diet — there’s smoking, for instance — but many, if not
most, of them are.
We’re spending $147 billion to
treat obesity, $116 billion to
treat diabetes, and hundreds of billions more to treat cardiovascular disease
and the many types of cancer that have been linked to the so-called Western
diet. One recent study estimated
that 30 percent of the increase in health care spending over the past 20 years
could be attributed to the soaring rate of obesity, a condition that now
accounts for nearly a tenth of all spending on health care.
The American way of eating has
become the elephant in the room in the debate over health care. The president
has made a few notable allusions to it, and, by planting her vegetable garden
on the South Lawn, Michelle Obama has tried to focus our attention on it. Just
last month, Mr. Obama talked about putting a farmers’ market in front of the
White House, and building new distribution networks to connect local farmers to
public schools so that student lunches might offer more fresh produce and fewer
Tater Tots. He’s even floated the idea of taxing soda.
But so far, food system reform has
not figured in the national conversation about health care reform. And so the
government is poised to go on encouraging America’s fast-food diet with its
farm policies even as it takes on added responsibilities for covering the
medical costs of that diet. To put it more bluntly, the government is putting
itself in the uncomfortable position of subsidizing both the costs of treating
Type 2 diabetes and the consumption of high-fructose corn syrup.
Why the disconnect? Probably because
reforming the food system is politically even more difficult than reforming the
health care system. At least in the health care battle, the administration can
count some powerful corporate interests on its side — like the large segment of
the Fortune 500 that has concluded the current system is unsustainable.
That is hardly the case when it
comes to challenging agribusiness. Cheap food is going to be popular as long as
the social and environmental costs of that food are charged to the future.
There’s lots of money to be made selling fast food and then treating the
diseases that fast food causes. One of the leading products of the American
food industry has become patients for the American health care industry.
The market for prescription drugs
and medical devices to manage Type 2 diabetes, which the Centers for Disease
Control estimates will afflict one in three Americans born after 2000, is one
of the brighter spots in the American economy. As things stand, the health care
industry finds it more profitable to treat chronic diseases than to prevent
them. There’s more money in amputating the limbs of diabetics than in
counseling them on diet and exercise.
As for the insurers, you would think
preventing chronic diseases would be good business, but, at least under the
current rules, it’s much better business simply to keep patients at risk for
chronic disease out of your pool of customers, whether through lifetime caps on
coverage or rules against pre-existing conditions or by figuring out ways to
toss patients overboard when they become ill.
But these rules may well be about to
change — and, when it comes to reforming the American diet and food system,
that step alone could be a game changer. Even under the weaker versions of
health care reform now on offer, health insurers would be required to take
everyone at the same rates, provide a standard level of coverage and keep
people on their rolls regardless of their health. Terms like “pre-existing
conditions” and “underwriting” would vanish from the health insurance rulebook
— and, when they do, the relationship between the health insurance industry and
the food industry will undergo a sea change.
The moment these new rules take
effect, health insurance companies will promptly discover they have a powerful
interest in reducing rates of obesity and chronic diseases linked to diet. A
patient with Type 2 diabetes incurs additional health care costs of more than
$6,600 a year; over a lifetime, that can come to more than $400,000. Insurers
will quickly figure out that every case of Type 2 diabetes they can prevent
adds $400,000 to their bottom line. Suddenly, every can of soda or Happy Meal
or chicken nugget on a school lunch menu will look like a threat to future
profits.
When health insurers can no longer
evade much of the cost of treating the collateral damage of the American diet,
the movement to reform the food system — everything from farm policy to food
marketing and school lunches — will acquire a powerful and wealthy ally,
something it hasn’t really ever had before.
AGRIBUSINESS dominates the
agriculture committees of Congress, and has swatted away most efforts at
reform. But what happens when the health insurance industry realizes that our system
of farm subsidies makes junk food cheap, and fresh produce dear, and thus
contributes to obesity and Type 2 diabetes? It will promptly get involved in
the fight over the farm bill — which is to say, the industry will begin buying
seats on those agriculture committees and demanding that the next bill be
written with the interests of the public health more firmly in mind.
In the same way much of the health
insurance industry threw its weight behind the campaign against smoking, we can
expect it to support, and perhaps even help pay for, public education efforts
like New York City’s bold new ad campaign against
drinking soda. At the moment, a federal campaign to discourage the consumption
of sweetened soft drinks is a political nonstarter, but few things could do
more to slow the rise of Type 2 diabetes among adolescents than to reduce their
soda consumption, which represents 15 percent of their caloric intake.
That’s why it’s easy to imagine the
industry throwing its weight behind a soda tax. School lunch reform would
become its cause, too, and in time the industry would come to see that the development
of regional food systems, which make fresh produce more available and reduce
dependence on heavily processed food from far away, could help prevent chronic
disease and reduce their costs.
Recently a team of designers from
M.I.T. and Columbia was asked by the foundation of the insurer UnitedHealthcare
to develop an innovative systems approach to tackling childhood obesity in
America. Their conclusion surprised the designers as much as their sponsor:
they determined that promoting the concept of a “foodshed” — a diversified,
regional food economy — could be the key to improving the American diet.
All of which suggests that passing a
health care reform bill, no matter how ambitious, is only the first step in
solving our health care crisis. To keep from bankrupting ourselves, we will
then have to get to work on improving our health — which means going to work on
the American way of eating.
But even if we get a health care
bill that does little more than require insurers to cover everyone on the same
basis, it could put us on that course.
For it will force the industry, and
the government, to take a good hard look at the elephant in the room and
galvanize a movement to slim it down.