Fat as Class War in Arizona

Is this some kind of sick April Fools Day spoof?

Arizona’s Republican governor reportedly has a bold new plan to pit fat Medicaid recipients against kidney-transplant candidates. Jan Brewer is proposing a $50 “fine” for overweight Medicaid patients who fail to slim down on doctors’ orders:

Ms. Brewer’s surcharge would apply only to only certain childless adults: Those who are obese or chronically ill, and those who smoke. They would need to work with a primary-care physician to develop a plan to help them lose weight and otherwise improve their health. Patients who don’t meet specified goals would be required to pay the $50, under terms of the proposal. [WSJ]

Medicaid is the major joint federal/state health insurance for low income people and the disabled. If the Republican-dominated state legislature approves Brewer’s plan, this will be the first time Medicaid has penalized clients for being “unhealthy.” The Wall Street Journal says this would be the first time Medicaid “has charged people for engaging in behavior deemed unhealthy,” but unlike smoking which would also reportedly be penalized under Brewer’s scheme, being overweight is not a behavior.

Demanding that poor people slim down and charging them extra if they don’t would be a cruel and regressive tax. What’s next, pillory stocks? The goal isn’t really to save money, or improve public health. The goal is to make government assistance as degrading as possible. I’m reminded of Rick Scott’s plan to test welfare recipients for drugs at their own expense.

If Arizona really cared about lowering health care costs, it would invest in primary prevention. That would mean putting healthy food and physical activity within the reach of every Arizonan, not gouging Medicaid patients after the fact.

A diet-or-pay scheme is not sound public health policy. Diets, even medically supervised diets, don’t reliably produce permanent weight loss. Furthermore, weight fluctuations may be even more dangerous than being steadily overweight.

It wouldn’t surprise me if this program cost more than it generates in revenues. After all, most diets fail, but $50 probably doesn’t come close to covering the costs of medical supervision. Fines from overweight Medicaid patients are not going to pay for a lot of kidney transplants.

The sick irony is that poverty is an independent risk factor for obesity. It’s simple arithmetic. High-nutrient, low-calorie foods like fruits, vegetables, and lean meats cost a lot more than low-nutrient, high-calorie staples rich in flour, sugar, and fats. So, if you’re shopping on a very tight budget, you have to consume a lot more calories to get your full complement of nutrients.

Is Brewer seriously proposing that the very poorest of the poor be made to pay even more because they can’t afford to be thin? Paying a $50 fine is cheaper than changing your eating habits for life. A $50 fine is cheaper than buying a decent pair of gym shoes so you can take a brisk walk without killing your knees. It costs a lot more than $50 to join a gym so you can exercise in an air conditioned room–which is no small thing in the Arizona heat, especially if you already have a chronic illness.

I emailed the governor’s office to request a copy of her proposal. I’ll let you know if they get back to me.

Update: Brewer’s fat fine plan appears in the fine print of a March 31 letter to Secretary of Health and Human Services Kathleen Sebelius requesting a “Demonstration Waiver” for Arizona’s Medicaid program.

You can download the document at the AHCCCS website, click on the Revised Waiver Proposal link. Here’s the relevant language:

In addition to flexibilities to assess eligibility, the State is seeking to pilot penalty and incentive strategies that would assist the State in partnering with the consumers to take responsibility for their own health care. For instance, all smokers enrolled in the childless adult population would be required to pay an annual fee of $50. In addition, childless adults who are obese and/or suffer from a chronic disease, such as diabetes, will need to work with their primary care physician to develop a care plan. Individuals who do not adhere to the plan and meet specified goals will be required to pay an annual fee of $50.

The program would also fine the parents of some obese children:

Children who are obese must meet a care plan outlined by their pediatrician and when steps are not taken to address the child’s obesity, a copayment will be assessed. If the child shows positive improvements under the guidelines and supervision of the pediatrician, the copayment will be waived and an incentive payment will be considered. Likewise, children who are managing a chronic condition will be excused from copayment requirements if they are managing their disease under the pediatrician’s supervision.

Brewer is trying to spin the “fat fines” program as a money saver to offset recent Medicaid cuts. The analogy of for-profit insurers charging higher rates to smokers and overweight customers is being bandied about. Citizens are being told that smokers should pay their own way.

However, it’s clear from her proposal that the program will be a heavily subsidized by federal tax dollars.

According to the document, Arizona plans to apply for grants through the Affordable Care Act to pay for this. The state also plans to spend a separate $400,000 federal grant on this program.

Update II: Brewer’s office got back to me with a copy of the proposal minutes after I posted the first update. I’d already found the documents I needed online, but I want to thank her staff for being so responsive.

HT: Amanda.

[Image via The Raucous Royals.]