January 5th, 2015
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The European Union Court of Justice has ruled that obesity may be considered a disability and employers may have to make accommodations. As with the ruling of the Social Security Administration in this country, the EU court ruled that obesity itself is not a disability but it can cause hindrances that can be considered a disability.
In the United States, several laws are involved. Under the Americans with Disabilities Act, morbid or severe obesity may be considered a disability, irrespective to any underlying physiological disorder. Several courts and the Equal Employment Opportunity Commission (EEOC) are re-examining this issue. (The EEOC is looking at the applicability of the ADA to employer wellness programs.)
The Social Security Administration (SSA) in 1999 issued a rule that removed obesity from its Listing of Impairments because of the wide variation in body weight and effect on employment. But the SSA continued to consider obesity as a medically determinable impairment and may be considered when combined with other impairments in determining disability. (Disclosure: I was very involved in the re-opening of this rule-making and advocated for equal treatment of cases of obesity, especially morbid obesity, in the eligibility of persons to qualify for disability income support.)
Predictably, the chorus offended at any social equity for persons with obesity manned the ramparts to warn about the dangers of treating obesity as a disability. (The decision of the American Medical Association that recognized obesity as a disease met the same kind of resistance. See here, here and here.) For example, this opinion piece by the Editorial Board of the Chicago Tribune sees creeping European thinking infecting Americans and distorting the Americans with Disabilities Act. Woe are we if employers have to accommodate the more than 15 million people in the US who have morbid or severe obesity! The Editorial Board mistakenly states that the basic idea of the ADA was, “empowering people who are the unfortunate victims of fate. Obesity is usually the result of individual decisions, and it can be ameliorated by individual decisions. Those facts (?) argue for leaving the government out of this realm.” As someone who lobbied for passage of the ADA, I can attest that it was not for “unfortunate victims of fate.” It was for all persons with an actual or perceived disabling condition, even like HIV/AIDs, regardless of the contribution of individual behavior. The ADA’s coverage of “perceived” disabling conditions easily refutes the Editorial Board’s so-called “facts.”
A contrary view is offered by Deborah A. Cohen of the Rand Corporation who points to the regulation of alcohol in the United States to successfully reduce consumption as a model. In a op-ed essay in Newsweek she states, “So long as restaurants continue to automatically serve quantities of food in excess of what customers can burn, and supermarkets promote junk foods with considerably more vigor than healthy foods, it can be anticipated that most people will eat too much and become at risk for chronic diseases.”
The EEOC will play a critical role in the evolution of considering obesity as a disabling condition. Some years ago the EEOC took the position that severe or morbid obesity was an impairment, although not obesity per se. However, in 2008, Congress enacted the Americans with Disability Amendments Act which generally broadened the definition of disability. Subsequently, the EEOC in 2011 removed from its guidances language stating, “except in rare circumstances, obesity is not considered a disabling impairment.”
We have seen that employees with obesity suffer a well-documented “wage penalty” for their condition, as well as hostility in the workplace. Offering legal protection for persons with obesity only provides the same level of equity with other persons experiencing a disability or perceived disability. It appears that the national debate over individual responsibility versus control over environmental influences will continue for sometime.
November 13th, 2014
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Want an example? The November 13, 2014 edition of the Washington Post carries a sad story of a talented young man who put on weight, was bullied at school and turned to marijuana to ease the pain of the taunting. The marijuana use brought him into contact with violent drug dealers who are suspected in his shooting. This case will no doubt be listed as a drug-related crime and the shooter or shooters will probably be found and prosecuted. But the bullies at his school, his teachers and administrators, and his classmates who did nothing…they will not shoulder any responsibility but their guilt will be just as great.
June 19th, 2014
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The Fiscal Times reports on new study from Scott Kahan MD at George Washington University and director of the STOP Alliance estimating costs of obesity at $300 billion.
January 15th, 2014
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If you read nothing else about obesity this year, read this elegant summary of where we stand from John Cawley, Ph.D. of Cornell University.
July 8th, 2013
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Supposed you woke up and the TV news and newspapers revealed that scientists had discovered a global threat affecting all races, both genders, reducing lifespans and causing millions of cases of disabilities, likely to cost billions of dollars a year. There was no clear cause and no treatment which seemed available, except, in some cases, surgically removing part of the GI track seemed to work…for a while.
What would you say? “Who cares”? “It’s their own fault”? “How much is this going to cost me?” Perhaps, you would call your Congressional representative and Senator and demand a crash research program to find a cure? Or you could quibble for, say, forty years or so, over who is to blame and whether this “threat” is a condition, syndrome, risk factor or (God forbid!) a disease? Well, the latter is pretty much what we have been doing about obesity. Three new papers show the impact of obesity on mortality, disability and disability-related health care costs, reminding us of the toll this disease takes on the human body.
First, regarding mortality, a great number of studies have been published and the public is still confused. Now, Chang and colleagues, have published a paper in which they are able to predict life years lost associated with obesity-related diseases for non-smoking US adults. They found that obesity-related comorbidities are associated with large decreases in life years and increases in mortality rates. Years of life lost is more marked for younger than older adults, for blacks more than whites, for males than females and for more obese than less obese. Their study confirmed that being obese or underweight increased the risk of mortality. Furthermore, an obesity-related disease, such as coronary heart disease, hypertension, diabetes and stroke, increased the chances of dying and decreased life years by 0.2 to 11.7 years, depending on gender, race, BMI and age. Obesity-related diseases were expected to shorten lifespan of people in their 20s by more than 5 years, while people in their 60s were predicted to lose just under one year of life. See, Chang SH, Pollack LM, Colditz, Life Years Lost Associated with Obesity-Related Diseases for U.S. Non-Smoking Adults.
Obesity-related diseases are also only partially understood. Type 2 diabetes and heart disease are commonly associated with obesity but there are a host of other conditions which are less well-known and appreciated. Among these are the disabling conditions associated with obesity. Brian S. Armour, et al, have looked at disability prevalence among persons who are obese. Of the 25.4% of US adults who are obese (53.4 million), 41.7% reported a disability in contrast to 26.7% of those at a healthy weight and 28.5% of those who were overweight. Movement difficulty was the most common type of basic action difficulty, affecting 32.5% of the adults with obesity. Of course, movement difficulties can hinder physical activity for weight loss.
Work limitations affected 16.6% of the adults with obesity. Visual difficulty was the common sensory difficulty at 11.5%, probably attributable to type 2 diabetes. 20.5% of adults with obesity reported complex activity limitation, compared to 12% of those at a healthy weight. All estimates for disability were significantly higher for people who were obese compared to those with a healthy weight. The prevalence of cognitive difficulty, contrary to Hank Cardello’s implications, was low at 3.6% for persons with obesity. However, persons at a healthy weight had higher cognitive difficulty than those who are overweight, 2.9% v. 2.4%. Armour BS, Courtney—Long EA, Campbell VA, Wethington HR, Disability Prevalence among health weight, overweight, and obese adults. Obesity, 2013 Apr.21 (4); 852-5.
Wayne L. Anderson, Joshua M. Weiner and colleagues widen the picture of persons who are obese with disabilities in terms of health care costs. Their new study estimates the additional average health care expenditures for overweight and obese adults with and without disabilities. They found that people with disabilities who were obese had almost three times the additional average costs of obesity compared to people without disabilities, $2,459 v. $889. Prescription drug costs were 3 times higher and outpatient expenditures were 74% higher. People with disabilities in the 45-64 year age group had the highest obesity expenditures. Overweight people with and without disabilities had lower expenditures than normal-weight people with and without disabilities. The authors note, “A substantial portion of people with disabilities are obese. People with disabilities are at higher risk of obesity because some conditions such as arthritis and diabetes are characterized by high levels of functional impairment. Arthritis can readily limit mobility, which may result in substantial weight gain over time. For diabetes, weight gain can be a byproduct of insulin use if patients do not effectively manage their weight. The coexistence of disability, obesity, and serious chronic conditions may result in very high health care expenditures.” Anderson WL, Wiener JM, Khatutsky G, Armour, BS Obesity and People with Disabilities: The Implications for Health Care Expenditures. Obesity, 2013 June 26, (epub ahead of print).
So, obesity is a driver of mortality and morbidity but is not a disease? Eh?
February 7th, 2013
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Workers who are obese receive lower wages than their non-obese peers, especially white women working in firms which provide health insurance for their employees.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) prohibits employers from varying employee contributions based on health related factors. The current HIPAA provisions provide an exception which allows employers to vary contributions if they participate in employee wellness programs. The proposed regulation under the ACA expands the amount of the penalty/incentive to up to 30% of the cost of the employee’s health insurance premium for those meeting specified biometric targets, including Body Mass Index (BMI) or related weight metric.
Since this provision broadens the exception to the non-discrimination provisions, it is important to consider the extent, insofar as it can be determined of existing discrimination against persons because of their body weight. An expansion of the HIPAA provision should then be read in context of increasing the penalty paid by some employees for their excess body weight.
The justification for the ACA provision was that employees with poor lifestyle behaviors, especially smoking and obesity, should bear more of the employer-paid health insurance costs or demonstrate their efforts in making lifestyle changes in voluntary or mandatory wellness programs. Current research indicates that this premise is not accurate.
So who are most affected by these programs?
The biometrics used in such programs, include obesity, elevated triglycerides and blood pressure, are part of what is known as the metabolic syndrome. Approximately 34% of adults meet the National Cholesterol Education Program’s criteria for the metabolic syndrome. Older males and females from 40-59 years of age are about 3 times as likely as those 20-39 to meet the criteria for the metabolic syndrome. Males and females over 60 were more than 4 and 6 times respectively to meet the criteria. Overweight and obese males were 6 and 32 times as likely as normal weight males to the meet the criteria and overweight and obese females were 5 and 17 times as likely to meet the criteria. (See, Ervin RB, Prevalence of metabolic syndrome among adults 20 years of age and over, by sex, age, race and ethnicity, and body mass index: United States, 2003-2006. National Health Statistics Reports; No. 13. National Health Statistics metabolic syndrome – PubMed Results )
The prevalence of obesity and hypertension has significantly increased in non-Hispanic Whites and non-Hispanic Blacks in both men and women. Non-Hispanic Blacks have the highest prevalence of obesity and hypertension. Diabetes is increasing overall with Mexican-Americans showing the higher rates. Smoking is declining in all groups. Romero CX, et al, Changing Trends in the Prevalence and Disparities of Obesity and Other Cardiovascular Disease Risk Factors in Three Racial/Ethnic Groups of USA Adults. Adv Prev Med. 2012:172423.
The study by Jay Bhattacharya and M. Kate Bundorf of the Stanford University School of Medicine looked at the issue: Who pays the healthcare costs associated with obesity? Using data from the National Longitudinal Survey of Youth and the Medical Expenditures Panel Survey, they made some startling findings:
Workers who are obese and who receive health insurance through their employers earn lower wages than their non-obese peers.
Workers who are obese and at firms not providing health insurance earn about the same as their thinner colleagues.
A substantial part of these wage penalties at firms offering insurance can be explained by the difference between obese and non-obese in expected medical care costs.
The obese with employer-sponsored health coverage bear the full cost of the incremental medical care associated with obesity, approximately $732.
Thus, their study finds that while it is nominally employers who pay for health insurance premiums, it is really employees who bear the cost of employer-sponsored insurance. Further, the wages of obese workers are lower than those of their normal weight peers, and in the case of white women, the relationship appears to be causal. It is obese white women who bear the burden of lower wages due in part to the higher costs of insuring these workers. In firms providing employer based health insurance, obese women experience a wage penalty of $2.64 per hour. The penalty comes out to $5,784, above the average individual health insurance premium or 1/3 of a family premium. In firms which do not provide health insurance, there is no significant wage penalty.
Not surprisingly, men and women with obesity report a higher percentage of common medical conditions, including diabetes, asthma, hypertension, non-specific joint pain and arthritis. Women with obesity are nearly 10% more likely to have arthritis than their non-obese peers, while for men with obesity, the differential is only 6%. It is only for arthritis that obese individuals spend more than thin individuals. They state, “For female workers with arthritis, the medical expenditure difference between obese and thin individuals is $1,956; for male workers with arthritis, the difference is $1,224. Clearly, differences between men and women are an important part of the reason why obese female workers spend so much more on medical care than thin female workers, while obese male workers spend about the same as thin male workers.” The authors calculate the yearly wage penalty on obese women employed in firms providing health insurance is $5,784. Bhattacharya J, Bundorf, MK, The incidence of the healthcare costs of obesity, Journal of Health Economics 2009 May;28(3):649-58.
Two points from this study are critical. First, women with obesity already pay their health insurance premium through a reduction in wages. Thus, a mandatory health contingent program in which the employee is penalized for not attaining an employer determined health metric, such as BMI, actually has the worker paying up to 130% of the health insurance premium. It is this figure which is the true impact of the proposed rule.
Second, the medical conditions of men and women with obesity such as asthma, arthritis, hypertension, etc. can make physical activity difficult or impossible, due to both the physical limitations of such conditions as well as the time and out-of-pocket costs of managing these conditions.
The wage penalty may actually be higher, especially for both men and women at the upper end of the BMI spectrum. In a paper published in 2011, Lisa Powell and colleagues found that a one-unit increase in BMI is directly associated with 1.83% lower hourly wages for women. Late-teen obesity is indirectly associated with 3.5% lower hourly wage for both men and women. Therefore, the wage penalty is significantly larger than previous studies indicated. Han E, Norton EC, Powell LM, Direct and indirect effects of body weight on adult wages. Economics & Human Biology 2011 Dec;4(11):381-392.
The wage penalty may explain the greater perception of employment discrimination among persons with obesity. In one study, results indicate that women are over 16 times more likely than men to perceive employment related discrimination and identify weight as the basis for their discriminatory experience. In addition, overweight respondents were 12 times more likely than normal weight respondents to report weight-related employment discrimination, obese respondents 37 times more likely, and severely obese respondents more than 100 times more likely. Roehling M, Roehling P, Pichler S, The relationship between body weight and perceived weight-related employment discrimination: the role of sex and race. Journal of Vocational Behavior, 71; 2 (Oct 2007);300-318.
April 19th, 2012
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Researchers at the Mayo Clinic have found significantly higher costs associated with obesity, especially morbid obesity, than smoking. Smokers had average health costs $1,275 higher than non-smokers but the added costs for persons with morbid obesity were $5,500 per year. http://insurancenewsnet.com/article.aspx?id=338975&type=newswires