Of the eight goals for health care reform laid out in President Obama's 2010 budget, just one has more to do with patients than with providers or insurers: "Investing in prevention and wellness."
Experts agree that the easiest way to cut down on the cost of care is to make people healthier before they get sick, something the government could encourage by promoting good habits and wellness programs. But proposed taxes on fattening foods and drinks have gotten little traction, and even public health programs -- like school nutrition or building bike paths -- aren't getting much play. They bring up the morally dicey issue of whether the government should have a role in people's fitness.
According to a study published in the journal Health Affairs, the medical costs of obesity alone were as high as $147 billion in 2008, with a large portion of that paid by Medicare and Medicaid. Barry Popkin, the director of the University of North Carolina's Interdisciplinary Obesity Center, said the best method to cut down the number of people being treated for heart disease and other chronic conditions linked to weight would be a tax on sugary drinks like sodas or non-organic juices, an idea floated in the Senate Finance Committee.
According to a Congressional Budget Office report, a tax of just 3 cents per 12 ounces of sugary beverage would raise $50 billion in 10 years, and a 25-cent tax per ounce of alcohol would raise $60 billion. Popkin has research coming out soon that he says will show a defined link between reducing sugary drinks and obesity. Other studies have said the same about alcohol. And a University of Florida study concluded that raising the price of beverages lowered consumption.
Some have also proposed a tax on fatty foods, an idea first floated by Yale University professor Kelly Brownell in 1994. A new study from the Urban Institute and the University of Virginia showed that a 10 percent sales tax on fattening foods could raise $522 billion over a decade. Three states -- California, Maryland and Maine -- tried such snack taxes in the '90s, though all were repealed. In California, citizens initiated and passed a ballot measure to scrap the tax just a year after its launch due to complaints about how the program was administered and higher food prices.
One major argument against food and beverage taxes is that they could be regressive, affecting low-income consumers that can't afford more expensive, healthier products. There are also concerns that they would create a so-called nanny state.
"There's no more personal choice than how Americans choose to spend their hard-earned money and then the choices they make on the foods and beverages they consume," said Kevin Keane, a spokesman for the American Beverage Association. "When the government tells people what foods and beverages they should eat or drink, that crosses a line for many people."
Basic questions also remain about how effective the government can be in changing the country's health habits; Prohibition stands as a frequently-cited example of the government's failure to alter social norms. But John Shiels, vice president of health care policy firm the Lewin Group, said the government effectively saved lives and altered the culture with motorcycle helmet and seat belt laws. California placed a 25-cent tax on cigarettes in 1988 and has seen the rate of adult smoking drop dramatically in the years since. Other states and the federal government followed with more cigarette taxes, leading to an overall drop in smoking-related diseases and significant revenues.
Neal Kohatsu, chief of the cancer control branch of the California Department of Public Health, said that the cigarette tax was hit with the same sorts of criticism as beverage and food taxes -- that it unfairly targeted smokers and gave the government too much control. But he said that it actually had strong support, even from smokers.
"Many people don't know that polling shows the great majority of smokers want to quit and a majority favor healthier environments," Kohatsu said. "It's clearly a health risk for everyone, so it's not just an individual habit."
The beverage tax isn't likely to make it in the final health care bill, however (Senate Finance Chairman Max Baucus, D-Mont., said the tax was "on life support" in June), and the fat tax never even entered serious discussions. Popkin said that had a lot to do with the powerful food industry not wanting its products taxed.
Despite the political resistance such measures face, health experts say simple public health programs like posting calorie counts on restaurant menus or promoting nutrition in schools make people healthier and deserve funding. A 2008 report from Trust for America's Health claimed that an investment of $10 per person per year in public health initiatives could save more than $16 billion a year within five years.
"We think this is a smart way to go," said Richard Hamburg, director of government relations for the Trust for America's Health. "We know that there are population-based interventions that can reduce chronic disease, save lives and save money." As examples, Hamburg cited increasing funding for physical education in schools, creating gardens in schools or communities, building bike paths and subsidizing the cost of produce.
All health care bills currently in discussion include grant extensions for public health programs and a national strategy to encourage fitness and prevent chronic illnesses. Among the projects that have been discussed in Congress are posting calorie counts on restaurant menus, giving tax credits to employers that promote wellness and encouraging the construction of bike and pedestrian paths.
Many states and cities have successfully implemented similar programs; California in particular has seen success through its tobacco control and physical activity and nutrition programs. Kohatsu said the programs are effective not because the government is mandating anything, but because they're encouraging people to change their habits. He said that's the model the federal government should take as well.
"Emphasizing a change in social norms and policy changes can be really effective in reducing health care costs," Kohatsu said. "We think that's something that should be the bedrock for health and health care reform."