Medicaid Fee for the Obese, Smokers and Diabetics
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image by Josh Sommers

A carrot or a stick, which one is better to get people do something they may not want to do?

That was the big question during one of the sessions I attended at SXSW on employee wellness programs. I believe the title of the session was “Employee Wellness: Farce or Untapped Potential”.  Most of us in the room, of course, believed that it was the later and not the former.  After all, as someone pointed out, if your employer is paying a large portion of your health insurance costs shouldn’t they have some sort of input into your health behaviors as well? And, after trying to get employees to move in the right direction with incentives like free healthy snacks and weight loss contests without wide scale success, many are going with the stick approach by charging smokers and the overweight more for insurance or withholding money from healthcare reimbursement accounts.

But what if the state, the government, is your health insurer? It seems in Arizona they want to start charging adult Medicaid recipients an annual fee of $50 if they are smokers, obese or diabetic.

At first glance, this doesn’t seem like such a bad idea. After all, this is the direction of the private sector.  Obesity and its resulting health complications cost our country $147 billion a year. With tight budgets, why shouldn’t those who continue to lead unhealthy lifestyles contribute a little extra?

Yet, those on Medicaid are already our lowest income citizens. You don’t go on Medicaid for the heck of it. You do it because you have no other choice. I should know, we were on Medicaid when I was a child. My mom, divorced and diagnosed with cancer, couldn’t work. It was our only option for a period of time.  So how effective is a $50 a year fee going to be on those who can least afford it? Will it force them not to sign up and, therefore, not receive any preventative care at all?

What about access to the tools needed to treat obesity, smoking and manage diabetes? For example, our lowest income areas are often those without access to quality food. “Food deserts” they are called. You can get soda and fast food easily and inexpensively but in these areas it’s nearly impossible to get fresh fruits and vegetables. In these conditions, how do you follow the doctor’s recommendation to lose weight? Combine that with lack of access to safe places to exercise or lack of resourcse to help someone learn how to exercise effectively and you’re setting someone up for failure.

And then there is my pet peeve-lumping all diabetics together. While type 2 diabetes is mainly driven by lifestyle factors, type 1 is not.  Although, I must admit, I know type 1’s who don’t eat right, don’t exercise, are overweight and actually have been given medication commonly used to treat type 2 diabetes because they have developed insulin resistance. So is there some other factor or measurement that would be used to administer the fee, like A1C?

I understand what they are trying to do. I understand the cost burden these conditions put on the system. Yet without the resources to help people defeat these conditions and change behaviors how effective is it really going to be? While private employers are assessing fees they are also offering education programs, onsite fitness classes, smoking cessation programs and onsite Weight Watchers meetings.  It’s not fair to impose a penalty without giving people the tools to change.  To the best of my knowledge, these components aren’t a part of Arizona’s plan.

So what can a state do with limited resources and a diverse population in need of help? Here are my thoughts:

  • Give vouchers for healthy foods (akin to WIC) in addition to current dollars in food assistance.
  • Tax fast food establishments in food deserts. Use the money to fund community gardens or tax incentives to fresh food vendors.
  • Upkeep and investment in parks and recreational trails. Make it easier and safer to participate in outdoor activities.
  • Expand the wellness visit provision currently available to Medicare recipients. This will give Medicaid recipients more access to registered dieticians, exercise professionals and diabetes educators.
  • Bring physical education back to the schools. Today’s overweight children are tomorrow’s obese adults.

Those are my thoughts. What are yours?

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