Should Health Care Be Prorated by Your BMI?

A chance meeting with a cardiologist had me thinking twice about our national priorities about men’s health care and the fiscal cliff.


Sunday morning I was watching the ABC national news.  I would prefer to keep my head in the sand but my wife likes to know what is going on in the world for some reason. One of the lead stories caught my attention for its stupidity. A bar somewhere in the SouthWest had been serving three obese women and the bar tender had entered into his computer the words “Fat Girls” on their check as a way to keep track of who they were.  Apparently it was for his eyes only but he forgot to erase it before handing them their bill.  The women were very upset–“scarred” in the words of the crack ABC reporter who provided footage of the bar manager being interviewed, the FB comment from the bar owner, and the first person testimony from the ladies in question with tears running down their quite full faces.



I watched the story and just asked myself what the heck? Is this really even a news story?

As luck would have it a few hours later I was at a neighborhood Christmas party.  I live in the “Longwood” section of Brookline which is literally a stone’s throw from the most prestigious cluster of hospitals and medical research facilities in the world. As usual I was awkwardly holding my diet coke as my wife socialized with ease.  I found myself standing with an older gentleman in a bow tie and 60s era black-rimmed glasses who I had seen at church but never spoken to.  He asked me a few questions about where I lived and what I did and then I asked him what his line of work might be.  He allowed that he was the head of cardiology at one of the best known hospitals in the world.

“But I will never see you at my practice,” he said quickly.  I asked why.  “Because you are not obese,” he responded.

What followed was a fascinating, if troubling discourse on medicine and our health care system that I can’t say that I fully understood but certainly caught my attention.

“I’m from Texas,” Mr. BowTie said. “Back in the day you had a heart attack and you died. Now we have all these drugs to keep people alive for years and years, wheeling them around in chairs and replacing their knees and all kinds of crazy stuff when the whole problem is a self-induced one to begin with.”

Mr. BowTie proceeded to tell me that indeed heart disease can be caused by a family history. But what use to be the norm is now a tiny fraction of the cases he sees.  “All I treat now are morbidly obese people whose hearts give out,” he said.  “And then we keep those obese people, more men than women mind you, alive forever at huge cost to everyone in the health care system.”

I thought back to John Stewart’s debate on the Daily Show with Chris Christie of New Jersey over Obamacare when he talked about the working mother with cancer and no coverage being just as much of an emergency as the victims of Sandy.  The thought crossed my mind for just an instant, even as a bleeding-hearted liberal democrat, maybe that is a false comparison based on what this guy is telling me.

Pretty soon my little Christmas party chat became an all-out discussion of national health care policy.  “One third of the health care costs in this country are directly or indirectly caused obesity,” he claimed.  “And that number is going down.”  I later sought to confirm that number and found a bunch of lower estimates online.  But even the ones put out by places like the national institute of health are alarmingly high. And no one seems to refute the idea that the percentage of our national health care dollar going to care for the obese is growing.  And growing quickly.

“What we need to do is force every citizen to pay for health care premiums based on their BMI,” he concluded.  “It’s the only fair way to force the issue.  Make people who consume more of the resources pay for it and hopefully incent people to grapple with the magnitude of this issue.”

I had to admit that between the fiscal cliff, global warming, and war in the Middle East, I really hadn’t been focussed on the impact of obesity on us as a people.  But Mr. Bowtie made a lot of sense as far as a complete non-expert could tell.

What do you think?

About Tom Matlack

Thomas Matlack is a venture capitalist.


  1. Use BMI as a measure stick on individuals while experts generally agree that BMI is only really useful when looking at an aggregated figure for a population over a certain size.

    I am willing to bet that a very large portion of the obese people are currently without health insurance. Even assuming that a higher prorate for obese will motivate them to lose weight it will only do so for those who are privileged enough to have health insurance or are in the process of getting insurance.

    Not for instance considering cutting subsidies to the sugar industry.

    Yeah, it seems like that Mr. Bowtie has the solution. Let the fat people die so we can protect the financial bottom line.

    I seems to me that when it comes to insurance we are getting closer and closer to the point that when an insurance company offers you an insurance you can safely decline to buy it because you can trust the insurance company’s calculation that they won’t have to pay anything to you.

  2. Allan Shore says:

    As I mentioned above, the typical 3 year old more regularly recognizes symbols of fast food outlets more consistently than images of themselves. Social and cultural practices demand empowering collective solutions which do not have to have govt involved. But blaming gluttony on people in a gluttonous culture is more about self perceptions. We change food practices by taking a voice in food systems.

    1 of 2 kids born after the year 2000 will likely get Type 2 diabetes.

    Think about these kid facts.


  3. wellokaythen says:

    I think there is actually some wisdom in this BMI idea, if we look at it metaphorically instead of literally. Obesity, fiscal crisis, and the debt crisis are similar to each other, in that they are all products of a society living beyond its means. When consumption becomes so central to our identity that it prevents healthy, balanced living, then you get these similar problems. When people gobble up more and more out of runaway greed or habit or ignorance or lack of good alternatives, then you get widespread obesity and debt.

    Meanwhile, the problem is compounded by the sense of entitlement people have that blinds them to their responsibility for the effects of their own choices. Government is in a budget crisis because of its own choices, but that’s not acceptable to say. The economy is in crisis because of the poor decisions of millions and millions of people (not just the 1%), but that’s taboo as well. People become one hundred pounds overweight not by accident but in large part because of choices, but that is also heretical.

    These problems have one big thing in common: it’s always someone else’s fault.

  4. wellokaythen says:

    Besides all the other issues people have raised here about the BMI, there’s also the specter of sex discrimination and racial discrimination. There is no way to make such a policy fair unless there are separate charts for men and women and different guidelines for people of different ancestry. I haven’t consulted a BMI chart in many years, not since it told me that at 6’5” I’m supposed to be no more than 200 pounds [!!!], but I seem to remember some modifications if you were African American or Asian. And, there was a separate chart for men and women.

    So, what we’re really talking about is charging based on something indexed to an individual’s sex and race. Why not charge African Americans more because of sickle cell traits and charge fair-skinned people more because of skin cancer risks?

  5. Jah, what exactly is willpower? A nice Calvinistic concept, for sure! Bad people are fat; good people are thin. Willpower doesn’t mean much when you’re exhausted; studies are now showing the links between sleep deprivation and the hunger hormone. Sleep deprivation also causes the fat-burning hormone levels to drop. Has anyone in these posts suggested our society should stop thinking stress is a good thing? (Stress has a great deal to do with sleep problems, as does working two and three jobs.)

    There are some great comments here, but none of you have recognized that there are people who will gain weight on 1500 calories a day. I was one of those people; I had to maintain weight on 800 calories a day and four to five hours of physical activity; that low a calorie intake reduces metabolic rate. Calories in, calories out is bullshit. Some of us are genetically structured to survive famine, particularly those of us with cold-climate genetics. I was hypothyroid and every damn doctor I saw completely ignored my glaring symptoms; one symptom is infection and I consequently walked around for two years with a kidney infection and had a massive pelvic infection which nearly killed me. In 1976, Broda Barnes, PhD, MD, estimated that 40% of Americans were hypothyroid. If Dr Idiot Bowtie was so interested in cardiac health, I would suggest he read Dr Barnes’s research; Dr Barnes’s patients had extremely low rates of heart disease.

    I would also remind people that Dr Bowtie lives in the state with the world’s highest health care costs. I have seen no genuine interest in reducing health care costs, just in reducing people’s access to services and being SELF-RIGHTEOUS about headless fatties and smokers. What exactly does self-righteousness do for one’s health?

    And 6’2″ and 220 pounds being obese is absolutely absurd!

  6. I agree that BMI is a poor scale. It should be bodyfat percentage.

    There is a causative correlation between excess adipose tissue and health problems. I don’t care who knows a healthy fat person and an unhealthy thin person – personal examples don’t matter when we’re discussing trends, and trends simply matter more. There are “plenty of people” who smoke for a lifetime but don’t have cancer (and people who have never smoked but get cancer anyway). There is STILL a link between smoking and cancer. There are “plenty of people” who have unprotected sex with a high number of untested partners who have no STI’s (and people who get STIs despite having only one sexual partner). There is STILL a link between regularly having unprotected anonymous sex and contracting STIs.

    But, of course, I’ll be called a bad guy or an abuser or a bully for pointing out that being overweight is unhealthy, because overweight people are so sensitive that we have to pretend that reality isn’t reality.

    • People are “sensitive” on obesity sometimes because like racism, sexism, etc., the victims aren’t responsible for getting the label. We live in a system that pays food business to serve poor foods that make fatness happen. If we look to turn Burgers Against Obesity using empowerment strategies the abusive system changes. My idea is about collective action not government mandates or personal criticisms. Nice piece though.

  7. Richard Aubrey says:

    Precisely. I get to determine what I eat. Not you, not the government.
    And “sentencing” isn’t theh same as “preferring”. Loaded words should be less obvious.

  8. Richard Aubrey says:

    My father was supposedly the fastest end in whatever conference UConn was in in the early Forties. He was 6’1.5″, 185. Today, he’d be overweight on the recently ratcheted down tables. Are you freaking kidding me?
    When I got out of OCS, underfed, overworked, could run all day and whatnot, I was 6’2″, 205. Overweight. Not. Buying. It.
    Nope. What we have here is a bogus looming catastrophe designed to alarm the unwary and push yet another intrusion of the nanny state.
    That said, individually underwritten health insurance plans did charge extra for the obese, but that was at much higher BMI numbers than these BS tables.

    • Allan Shore says:

      I suspect you lack imagination. Enjoy your burger. Such thinking got us to sentencing many to a life of poor eating.

  9. Obesity, folks, is a structural issue. Is is an “ism” in the same sense that racism, sexism, classism, etc. reflecting their own much larger cultural injustices. To say this isn’t to assume that it has no impact on individuals; of course it does, which is in part why we get bothered by structural imbalances, structural violence. But saying this doesn’t mean that we should look to the impact on individuals to judge the response that is best. Is our goal to eradicate gender injustice by just fixing all the bad men one person at a time? No, we seek to change the underlying system and the hearts, minds and bellies of the victims will grown better for the change.

    To make effective change, we need large streams of advocacy money. Fast food is a big part of the problem so I suggest we tap into the free flow of nickels and dimes to turn Burgers Against Obesity (… this will give a voice to consumers and offer the ways and means for true improvement in the system.

    • Richard Aubrey says:

      Consumers already have a vioice. They like their Whoppers and, if I am guessing right, their voices might tell your voice to leave them alone.
      “Large streams of… money” Wow. Who could have foreseen that?

      • Sorry, Richard, but letting corporate interests take advantage of social and cultural elements (like the concept of eating as a community or family unit) without regard to the true impact is a bit of an out-dated opinion. Even the Earth itself is balking at that. The agreement is that when we allowed fast food in to our communities, we liked it; now they have taken over and control the flow of food interests and attitudes because they have figured out how much power is invested in the nickels and dimes of 135,000,000 who shop at these outlets on a daily basis. Taking a social interest in the changing game is not wrong any more than is saying that men don’t want to hear about the glass ceiling in the workplace and businesses don’t want to have to adapt to those other people of color who make my sales tactics less efficient. Structural injustices arise because even seemingly good ideas at the time have been proven wrong or biased by unrespected interests. Corporations were designed to reward and protect stockholder interests in the past; today we see they must respect stakeholder interests too … and that’s a different ballgame. Our voices in food end when we hand over our money at the checkout counter … but who is to say that should be the end game? The market is our to buy from and to shape for goodness and fairness too.

        As for Whoppers, perhaps but perhaps not. For most of my lifetime the MPG of cars didn’t change all that much. Now we are on the verge of a nearly instant doubling of those because green incentives have forced healthy changes in the car and battery industry. Lest you think that government engagement in this was bad, the same case can be made for making franchise food corporations adjust their outlook on their customers as well. Who knows, perhaps there is a Green Burger out there that some entrepreneur has invented but that can’t get past the greed protections. I suspect that we can turn Burgers Against Obesity without giving up what consumers really like about fast, convenient and even entertaining food menus.

        But change costs money … and we need to have resources to support change too.

        • Richard Aubrey says:

          So, Allan, what are you going to do when somebody tells you to take your idea someplace and goes ahead and orders a Whopper?
          You may recall that there is a war on drugs, right? How is that going?
          And mentioning “corporations” as if that actually means anything besides Booga booga got old a couple of generations ago.
          Why would the green burger be subject to the greed protections? Makes no sense. If the green burger could get past the customer’s mouth, the corps would be making all kinds of greedy money on it. Maybe you could save us all a good bit of time and go into the kitchen and devise a tasty green burger. But, if the government isn’t forcing people, it isn’t any fun, is it?

  10. Jeanne Shepard says:

    Way too simplistic. Firstly, skinny doesn’t equal heart healthy. Ultra marathoners die of heart attacks, too.
    Our collective weight has gone up over the past 40 years, ever since we were told by the McGovern committee to eat low fat. High carbs=high insulin and the resulting fat, plus increased diabetes.
    As a therapist in a nursing home, I see plenty of older people who are NOT obese who are recovering from joint replacements. The biggest thing that brings them into the health care system is a catastrophic fall.

    • Richard Aubrey says:

      WRT the McGovern committee. If a private enterprise had done as much damage as this nonsense, the officers would be crucified and the thing sued into oblivion forty times over. Luckily, it was government program and everbody knows these always work.

  11. It was said Dr. Bow-tie comes from a world renowned hospital. That usually indicates he’s working with a select group of people. Not your average “lower-middle class” or poverty stricken American. When you see top dollar clients on a daily basis, you’re likely to come up with a top dollar solution to the problem. Cheers for economics. Maybe it’s a great idea to us a grossly inaccurate system such as BMI, or better yet, use underwater weighing or something more expensive, but still charge based on BMI. While we’re using scales, let’s scale the medical billing down by class.

    Wealthy America can use the BMI scale multiplied by the La Tache Romanee they love to drink. While the middle class gets Dual-Energy X-ray Absorptiometry multiplied by the average cost of Fast food menu items. Aaaand for our poverty stricken? Well, I can’t even come up with something (I think is) witty and sarcastic for those of use who’ve never seen a world famous hospital. I guess they can scale the degree of “free” clinics.

  12. First this would hurt lower class and non-whites the most. As most research shows. Second any sane and competent personal trainer would tell you BMI recommendations don’t give a full picture on the health of an individual. Third what about the skinny fat people? Or the fact that as a poor woman I already have crappy access to good health care and affordable good food. Born with a hip problem I can’t just go for a run. There’s so much more I could say but I’m too frustrated that anyone would find this a good idea.

  13. Allan Shore says:

    At age 3 or so children typically recognize icons of McWhatever more readily than representations of themselves. Since 2000, 1 of 2 vulnerable kids of certain ethnicities are likely to have Type 2 diabetes by about teen years. Nickelodeon TV violates policies against advertising fast food to children. Which kid is “Dr.” Bowtie mad at? Blaming victims is nonsense. We need to stop expecting that we can exercise out of profit schemes. If we build a voice into food buying processes we can generate revenues to turn Burgers Against Obesity. Of course when we designed Take Our Daughters to Work Day as a gender justice initiative we expected more.

  14. Really? Their quite full faces? Wow.

    I think BMI is inaccurate based on muscle mass and width. I think if the US was truly concerned about obesity (in terms of prevention) they’d eradicate high fructose corn syrup, alter the industrialized farming of animal products so that we ate less, and the animals eaten were healthier from the get go, find ways to minimize chemicals in produce, and lower the content of sodium across the board, not to mention allow children real free time for play and creativity and exercise in school recess. Then maybe we’d see some change.

    I’ve met some amazingly unhealthy skinny people and some marathon runners who would rate “obese” on an BMI.

    But that would cost shareholders too much money so it won’t happen. Much better to blame it purely on willpower.

    Read some Michael Pollan, watch some documentaries on the food industry, read up on ghelin, look into how stress and lack of relaxation, play and rest play into heart disease and then talk about that.

    It’s not just fatty fats being fat. It’s a system. And it’s not a healthy one by any means.

    • JahBless101 says:

      I understand where you’re coming from, but doesn’t will power play a role? I don’t necessarily see this as an all or nothing issue, and taking freedom away from people is never a correct response (drunk driving a problem? Ban alcohol! Better yet, ban cars!).

      I think that any change requires people to take a good hard look at some uncomfortable facts. It’s incredibly easy to get defensive and deflect, and we continue to ride the carousel. You’re right that BMI is not the answer, and that it IS a system. But what I think the article underscores is the importance of focusing on the solution, and not the problem. Sure the system exists, but we have a powerful tool to dismantle that system (will power). Until we enact the sweeping changes to our system, we need to keep fighting with the tools we have at our disposal. However, in order to do that, we need to face uncomfortable truths and accept that we are accountable for our actions & decisions, and yes, our weight.

      • Yes, if one is not exercising, not eating healthy foods, and only doing self destructive things sure. But if you have known, as I have known, individuals who run marathons and are vegetarian but are still considered obese, what do you say to them? Tax them anyway?

  15. InsertNameHere says:

    BMI is a terrible tool, if you are muscular or broad of shoulder, you will come off as overweight on it even if it isn’t so. Using BMI would lead to some very muscular, athetic people being charged a premium and some thin couch potatoes getting a deal.

    • JahBless101 says:

      I completely agree. I am a former college athlete (football). I was a linebacker, so I have some meat on my bones but I’ve improved my fitness greatly since my playing days ended. I work out frequently, l just completed the tough mudder, I can dunk a basketball and I’m training for my first marathon. But at 6’2″, 220 lbs, I’ll forever be labeled as obese.

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