Megan McArdle is on a tear about health care and obesity of late, castigating the nanny-staters and green eyeshaders for their moral hectoring.
The other major reason that I am against national health care is the increasing license it gives elites to wrap their claws around every aspect of everyone's life. Look at the uptick in stories on obesity in the context of health care reform. Fat people are a problem! They're killing themselves, and our budget! We must stop them! And what if people won't do it voluntarily? Because let's face it, so far, they won't. Making information, or fresh vegetables, available, hasn't worked--every intervention you can imagine on the voluntary front, and several involuntary ones, has already been tried either in supermarkets or public schools. Americans are getting fat because they're eating fattening foods, and not exercising. How far are we willing to go beyond calorie labelling on menus to get people to slim down?
This morning, she published an interview with the country's most incisive obesity skeptic, lawyer Paul Campos, where Campos advocates this approach:
"Here's an idea: Stop harrassing people about their weight. Because it appears that focusing on the idea that being fat actually makes people fatter. At least there's an extremely strong correlation there. I bet if we stopped demonizing fatness people would actually be a bit thinner. They'd certainly be happier and healthier."
The obesity movement has its skeptics, who, like Campos, use legitimate questions about obesity research to question whether the correlation between obesity and poor health suggests causation or something entirely different, and whether what we assume to be the negative effects of being fat itself are in fact more closely related to cultural attitudes about being fat and skinny. These critiques are gaining currency among poststructuralist psychologists and feminists, which puts libertarians in interesting company. Actually, there is plenty of evidence that body fat itself, particularly when concentrated in the abdomen, is directly harmful.
Nonetheless, a dose of Campos in one's anti-obesity cocktail keeps one humble about assuming too much. The academic world tends to lump together the slightly overweight, the unhealthy people who have large body sizes, the pre-obese, the active obese and the sedentary obese all into one category. Doing this inevitably leads to public interest group fear-mongering and implies that the problem is unipolar and thus solvable by their preferred approach. Campos -- and McArdle -- are right to approach the obesity issue with a skeptical, critical eye. But even Campos -- and you can see this in his interview with McArdle and in his book, The Obesity Myth -- does not make the claim that food consumption and lifestyle aren't public health problems.
McArdle approaches obesity as if it were a Foucauldian construct: a category invented by the government to justify an exercise of power. The government has no business intervening on the level of individual choice and it shouldn't get into the business of behavioral suasion because it always fails. She's right to note that information about health risks associated with overconsuming fat and sugar and salt are saturated throughout society, even supersaturated. Everyone knows how bad this stuff can be. For her, that's the end of the argument. Government can help to provide information about how to make better choices, but it cannot and should not try to persuade people to make better choices. Indeed, the push for people to make better choices produces the stigma that makes the bad thing bad in the first place.
This assumes that the stigma itself is misplaced. It isn't. Fat stigma is bad and harmful, and it ought to be reduced. But reducing fat stigma doesn't reduce the incidence of obesity; it actually seems to increase it in certain populations. What produces fat stigma is not a government or culture that hectors people to lose weight and exercise and then excoriates them when they can't; it's a government that expects individuals to lose weight on their own (which is next to impossible) while making policy that keeps people fat. The discrepancy between expectations and reality is cruel, especially for children.
For one thing, we have no idea whether the (real) epidemic of childhood obesity will change the conventional economic modeling of obesity in the future. But it's hard to imagine that it won't. Consider that Type II diabetes rates are skyrocketing among pre-pubescents. (Hard to call it "adult onset diabetes" now.) Treating diabetes for life is expensive, and we have no way of reliably estimating how expensive it will be. (We don't know who will pay for the coverage -- private insurers? The diabetics themselves? The government? All three?)
Labeling obesity a "problem" isn't a behavioral intervention: it's a social structure intervention. And here's where the individual model really breaks down, even for those who don't blame obese people, per se, for their obesity. Obesity is highly correlated with socioeconomic status. And it is a most acute problem among young minorities: African American women, Mexican-American boys, and Native American children have much higher rates of obesity than white children do. Poor kids tend to be more obese than wealthier or middle class children. The reason for these disparities are both obvious and counterintuitive: in general, people tend to eat what they can, which means that they buy the food they have access to. Wealthier people and people living in suburbs have access. Geographic location often correlates with lifestyle; history and social norms tend to be different, too, among ethnic groups.
McArdle is right that it it's not fair for government to lecture people about weight loss and exercise, but she's right for the wrong reason: policy choices -- ag subsidies, zoning laws, education and budget priorities -- create a flow that, absent any intervention, are sweeping many young kids, particularly poorer kids of color, into obesity. Government's role isn't to scold; it's to make better policy choices. She's wrong about the interventions, too: some, like a physical education project in Somerville, Mass., seem to be working. Taking fast food vending machines out of schools and weighing children at least once a year has arrested the obesity growth rate in Arkansas. Nationally, the obesity growth rate also seems to be be slowing.
Think a little about smoking. Though the decline in smoking rates cannot reliably be linked to any change in health care costs, it can be linked, causally, to a decline in heart disease and to declines in the rates of certain types of cancer.
People suffer less. The reason for the decline in smoking rates? Cigarette taxes, the rise of the smoker's stigma, the growing perception that cigarette companies were deliberately manipulating nicotine levels and lied about it. In terms of cost, all those ex-smokers and potentially-smoker-non-smokers who're lying around these days are probably adding a bit to what we pay for in health care. After all, nonsmokers tend to spend more money on health care than smokers because non-smokers tend to trust the medical establishment more than smokers do.
Lo and behold, government policy has helped ensure that the raw foodstuffs that go into all the starchy, sugary foods that we eat are much cheaper. And when compared to the consumer price index, fruits, vegetables and healthy foods are more expensive than they were 30 years ago. If government policy influences diet on a macro scale, and if there is evidence that the diet is harmful, then, in theory, there would be no additional intervention if, say, Congress began to subsidize tomatoes in the same way it subsidizes corn, just a change in policy.
None of this argues for a soda tax, or a tax on sugar, or a ban on, say, food marketing to children. It's just to say that if the obesity epidemic was nurtured by policy -- and it clearly was -- perhaps it can be undone by policy, too.