Death rates were highest among those with a B.M.I. of 35 or more.

Which seems to support the idea that 35 is a pretty good threshold for people to make sure they avoid. I believe Alabama set the threshold this high in order to not penalize anyone who is healthy, but still has a higher BMI than normal.

It does say that being overweight in the 25 to 30 range isn’t an indication of being in awful health–which makes perfect sense and seems to be recognized by what Alabama is doing.

Some people who smoke don’t get lung cancer and somehow seem to avoid other health problems, but that doesn’t mean it isn’t a good metric. I still think you are going to be very hard pressed to find someone with a BMI over 35 who would not benefit from activities designed to lower their BMI.

Regarding the IQ analogy it sounds like you are saying that someone with an extremely low IQ can function in the same manner as someone with an IQ of 100? I know Mensa members (top 98%) and I know people in the bottom 25%. There is a very big difference in what they are functionally capable of. I’m not sure what studies you have seen that prove otherwise.

Our basic disagreement is over whether or not a BMI of 35 should require someone to see a doctor and follow the doctors recommendations (along with other wellness indicators). I say, “yes”, and you say, “but there might be a healthy person with a BMI of 35–measure something else”.

And regarding your BMI it is almost certainly well under 35. If you have a lot of muscle mass from your frequent work outs it probably even below 30.

@Deb – I think your experiences most accurately reflect the majority of what is going on in people who are extremely large and don’t lose weight.

I have yet to meet anyone who is in the 35 BMI range who eats healthy (type of food and quantity) and gets even a moderate amount of exercise (walking 20 to 30 minutes a day). I’m open to the possibility that such a person might–just might exist, but it is probably very very rare.

I’m pretty self-motivated, but for some, this kind of monetary motivation could be the thing that helps them move in the right direction.

And the fact that you sound like you’re at a pretty reasonable weight and seem happy with how you’re doing, I’d have to say no, you’re not dragging me down. And I hope it stays that way.

But recent studies show that fitness may be a far better indicator of health than BMI. See http://www.nytimes.com/2008/08/19/health/19well.html

I think you can be fit and fat. And you can be skinny and unfit. And have serious health problems.

Again, my point is that you shouldn’t automatically penalize people who match a certain arbitrary measurement, that may in and of itself be inexact. Just as you shouldn’t assume that all people with, say, a certain IQ number are automatically going to have cognitive and functional problems. That has been proven untrue time and again.

But to answer your question, yes, if your BMI is above 35 and you don’t do anything you would be a statistical abnormality if you had lower health care costs than the average of a group of people with a BMI of 25. (This is particularly true if your BMI goes up as you age as it does with most people.)

Also the Alabama plan isn’t just for people with extremely high BMI. It also addresses people who smoke, have high cholesterol, etc.

I think adding a surcharge for being fat is discriminatory and does not address the real problem.

I would be considered fat by many (5′ 3″, 180), yet my blood pressure is a very normal 118/60 and my cholesterol level a very reasonable 140. I work out 2x a week and take two yoga classes weekly. I am a belly dancer and rehearse several times a week for my own practice and, when prepping for a show, often have 2 or 3 rehearsals a week. Earlier this year, I decided to phase in vegetarianism and do not eat beef or pork (taking it one animal at a time) I do not buy or eat junk food. I do not smoke.

Still think I am a health risk and a drag on the insurance system?

It would be more accurate and fair to add surcharges for such issues as smoking and *untreated* high blood pressure – issues that can be directly addressed by precise measures (nicotine patches, blood pressure medication, etc) and for which results can be directly linked to the treatment.

The US spends somewhere around $140 billion (yes that is right billion) dealing with issues caused by people being too fat. That means about 6% of all healthcare costs are related to people being overweight.

If people who rode horses required an extra $1,700 (the amount Alabama found fat people cost over normal people) in healthcare costs each year than non-riders, I’d be all for insurance companies charging them extra if they want to continue riding horses.

People have gotten so accustomed to not having responsibility for their actions that they get upset at the suggestion that those with poor self-discipline might have to pay a small portion of their extra healthcare expense.

Comment: That’s true, but then how about people who choose to engage in sports or other activities with a high risk of injury? Are they stealing from more “careful” people when they break their necks falling off horses or diving out of airplanes? And how about people who engage in risky behaviors like having unprotected sex? When they contract HIV or other STDs, aren’t they “stealing” from the responsible people who use protection?

It seems to me that unless you’re going to levy charges against everyone for every possible thing, targeting obese people seems kind of unfair. No one is perfect, and while the obese person “wears” their “imperfection” you can have a bunch of skinny people who are also driving up health care costs with their actions and behaviors.

Since you could come up with a “charge” for almost everyone (the skinny person who puts salt on everything even though they have high BP, the skinny person who has high cholesterol, etc.) I think it’s easier and nicer to just keep things the way they are. Very few people are perfect, so someone would usually be getting charged for something.

On the other hand, I have a co-worker who is in the same boat (severely obese). A couple of years ago, her boss offered her $100 for every 25 pounds she lost & he would pay for her WW 100%. She started going to WW faithfully every week. She started losing weight. She got the first $100 & then had a couple of injuries followed by a heart problem and completely quit…gaining back everything and then some. The partners at work beg her to go back, but she just won’t. She says that there is a problem with her thyroid & she just can’t lose the weight…even though it was working out great for her when she went to WW.

All-in-all a person has to have an incentive to lose weight (monetary, health, wedding, whatever). They have to be taught how to lose weight. They need encouragement (maybe a friend going to meetings with them or exercising with them). And finally they have to get excited about losing the weight. If they are ho-hum about it, they aren’t going to lose it no matter what others say. Yes there are many out there with eating disorders, but I highly doubt that if you could prove that you have a BMI of above 35…35!!! due to some highly irregular physical ailment that the State of Alabama would continue charge you the $25. In your article you state that a person of 5′6″ would have to weigh about 220 pounds to have a BMI that high. That is a severe problem.

I want to thank you for the back & forth conversations about this issue.

You seem to be advocating a system where people can be as unhealthy as they like and their healthcare should be paid for by the healthy people.

On a base level my disagreement is this: I believe people should take responsibility for their own actions and am in favor of changes that help encourage this. You appear to believe that people should be able to ignore responsibility for their own actions.

With such a fundamental difference in ideas, we would probably have very little ground in common to even begin a discussion.

There seems to be a misconception that it is healthy for some people to be obese. (Keep in mind that a BMI of 30 is considered obese so 35 is well beyond this.) I think this is what is driving the idea that being fat is a disability.

There are some types of diseases that make it more likely for a person to gain weight, but that just means they need to work extra hard. It doesn’t mean that it is somehow healthy for them to let their BMI go above 35. (Obviously I don’t know about every possible disease, so maybe there is some type of condition where this isn’t the case, but even if there is, I’d bet it is pretty rare.)

@Marc – The Alabama program says that everyone has to do a health screening and get recommendations. They should all have plenty of information on how to deal with their issues whether it is cholesterol or obesity.

Also if people don’t know how to keep their weight under 35, I’d say they are almost intentionally ignoring stuff. It is a pretty hot topic in the US. Also keep in mind that the people referred to in Alabama are people who have an insurance program with a free wellness program.

I still stand by my original argument – that wellness incentives need to be tailored to the individual’s health to be the most effective. Broad initiatives will necessarily encourage some more than others depending on what metric they target (and perhaps even discourage some).

Practically speaking, it may be more realistic to stick to BMI as a standard metric, given the logistics of rolling out a program for a mass audience while maintaining a degree of individualization.

The question then becomes: who, if anyone, would be discouraged? Is it a disproportionate amount of people with a BMI above 35? If so, the program fails its original intent.

I’d be interested to see some test cases at different companies in different areas of the country. If there’s one thing the U.S. isn’t lacking (unfortunately) it is obese people.