The promise of that system is undeniably alluring: whatever your ailment, a pill or a procedure will fix it. Yet the promise hasn’t been kept. For all the miracles that modern medicine really does perform, it is not the primary determinant of most people’s health. J. Michael McGinnis, a senior scholar at the Institute of Medicine, has estimated that only 10 percent of early deaths are the result of substandard medical care. About 20 percent stem from social and physical environments, and 30 percent from genetics. The biggest contributor, at 40 percent, is behavior.
Today, the great American public-health problem is indeed obesity. The statistics have become rote, but consider that people in their 50s are about 20 pounds heavier on average than 50-somethings were in the late 1970s. As a convenient point of reference, a typical car tire weighs 20 pounds.
This extra weight has caused a sharp increase in chronic diseases, like diabetes, that are unusually costly. Other public-health scourges, like lung cancer, have tended to kill their victims quickly, which (in the most tragic possible way) holds down their long-term cost. Obesity is different. A recent article in Health Affairs estimated its annual cost to be $147 billion and growing. That translates into $1,250 per household, mostly in taxes and insurance premiums.
A natural response to this cost would be to say that the people imposing it on society should be required to pay it. Cosgrove mentioned to me an idea that some economists favor: charging higher health-insurance premiums to anyone with a certain body-mass index. Harsh? Yes. Fair? You can see the argument. And yet it turns out that the obese already do pay something resembling their fair share of medical costs, albeit in an indirect way. Overweight workers are paid less than similarly qualified, thinner colleagues, according to research by Jay Bhattacharya and M. Kate Bundorf of Stanford. The cause isn’t entirely clear. But the size of the wage difference is roughly similar to the size of the difference in their medical costs.
It’s also worth noting that the obese, as well as any of the rest of us suffering from a medical condition affected by behavior, already have plenty of incentive to get healthy. But we struggle to do so. Daily life gets in the way. Inertia triumphs.
The question of personal responsibility, then, ends up being more complicated than it may seem. It’s hard to argue that Americans have collectively become more irresponsible over the last 30 years; the murder rate has plummeted, and divorce and abortion rates have fallen. And our genes certainly haven’t changed in 30 years.
What has changed is our environment. Parents are working longer, and takeout meals have become a default dinner. Gym classes have been cut. The real price of soda has fallen 33 percent over the last three decades. The real price of fruit and vegetables has risen more than 40 percent.
The solutions to these problems are beyond the control of any individual. They involve a different sort of responsibility: civic — even political — responsibility. They depend on the kind of collective action that helped cut smoking rates nearly in half. Anyone who smoked in an elementary-school hallway today would be thrown out of the building. But if you served an obesity-inducing, federally financed meal to a kindergartner, you would fit right in. Taxes on tobacco, meanwhile, have skyrocketed. A modest tax on sodas — one of the few proposals in the various health-reform bills aimed at health, rather than health care — has struggled to get through Congress.
