This is true and not really relevant to the point that people who can't afford healthcare get very sick before they go to a doctor and then their care is more expensive and has worse outcomes.

One hospital was having so many resources consumed by a relatively small number of very ill homeless people and concluded that housing them would be cheaper and more effective, so it did.

Health care really shouldn't be used to mean medical care per se. And that's one of the things that complicates such discussions.

https://news.ycombinator.com/item?id=34397790

> Health care really shouldn't be used to mean medical care per se. And that's one of the things that complicates such discussions.

Exactly.

Whole hospital floors are completely dedicated to patients with completely preventable diseases with proper lifestyle choices (uncontrolled type-II diabetes, most cardiac and vascular surgeries...). What these people needed a decade or two ago was someone to coach them/engage in a long term discussion about their labs and deteriorating health with them.

I can't help to think that defining healthcare exclusively as medical care is an attempt at further gatekeeping from a profession already known for these practices... I mean, what brings in more dollars for the provider, a series of hospitalizations and vascular surgeries or a few hours of consulting and coaching?

When I was fat, my insurance wouldn't cover any weight loss procedure (including just visiting my primary physician to discuss my options for weight loss-- a lovely $250 surprise) because I had no obesity-related health problems (heart disease, diabetes, joint issues, etc).

So a hospital can actually do a lot for fatties. Being able to talk to a nutritionist, set up a plan, gain access to any applicable medication, addressing out underlying inflammation/hormone/disordered eating...

> When I was fat, my insurance wouldn't cover any weight loss procedure (including just visiting my primary physician to discuss my options for weight loss-- a lovely $250 surprise) because I had no obesity-related health problems (heart disease, diabetes, joint issues, etc).

This is such a stupid, self-defeating policy for an insurer. Until your problem costs us a lot, don't you dare try to mitigate it on our dime!

>> self-defeating policy for an insurer.

Bariatric procedures can be included as a sort of "rider". This is typically written into self funded plans. Bariatric is not an essential coverage therefore ACA qualified plans do not typically include them - unless medically necessary.

In the US with healthcare tied to either employment or medicare, by the time these costs come around you're likely to either transfer out of this insurance or to the medicare option. Either way, it's someone else's problem (from the perspective of the current insurer).

I don’t know, looking at the percentages… I’m not sure preventative care for obese people is sustainable at this point.

Not that I shed tears for insurance companies, but I think this would be a lot of money. Now… the problem should have been addressed twenty years ago before it went critical.

After Obama Care, insurance companies profits are now capped at 8% (think that is the number) of revenue (ie premiums) in the US. So one way to grow revenue is to have higher costs per policy, pay out more, and charge higher premiums. If you are at 8% profit and you reduce your payouts as you are describing with preventative care, then you don't get to keep that money. You have to pay it back to the insurance buyers. Very perverse incentive.

The goal of the insurance companies is to make sure that all medical costs go up 10% every year so that their profits can increase and shareholders benefit. They are NOT negotiating lower pricing from medical providers, because why would they? Medical providers (and even individual care givers) have similar incentive structures to raise rates since they are paid only by insurance.

The last local obstetricians were pushed into hospitals and large groups by insurance companies paying them 20-40% of prevailing fees. They now make more per procedure and don't have to pay for facilities or do billing. Why would the insurance company pay so much less? Because once the cartel is created their profit (and pricing) will double.

That is for profit healthcare for you. Costs guaranteed to grow at DJI rates.

>>>>>That is for profit healthcare for you. Costs guaranteed to grow at DJI rates.

Not true. The Surgical Center of Oklahoma, a purely for profit clinic that does not take insurance, has not raised the rates for any of their services since 1995.

Yes, they have not raised rates...despite inflation

That's true profit healthcare.

What we have is a monster hybrid between government healthcare and subsidized, monopoly care

Unfortunately no one is lobbying for a truly free market in healthcare. For instance, at all the supply-side restrictions on new physicians and hospitals. Limited residency spots, certificates of need whatever.

Ideally the party in opposition to government-funded healthcare would do this.

>Not true. The Surgical Center of Oklahoma, a purely for profit clinic that does not take insurance, has not raised the rates for any of their services since 1995.

Source?

This portion of the linked article seems to contradict your claim of "has not raised the rates for any of their services since 1995"

>Had the pathology fees that apply to the examination of breast masses not increased, our price would be the same now as it was in 1997, but alas it is now $2,365. Only three other fees have increased since we began quoting them over the phone in 1997.

That said, I'll admit that the claim is broadly true.

Well, I'm not sure I buy it, and the actual date is 1997, but here is the story on Mises.org from 2021.

https://mises.org/wire/why-arent-there-more-free-market-surg...

That is not really how the modern medical insurance business works. Most group buyers such as employers are now self insured. The medical "insurance" companies no longer bear much risk, they merely administer claims and manage provider networks. This business is intensely competitive with low profit margins. Insurance companies have to negotiate lower costs in order to sell to their customers, which are primarily employers that buy plans on behalf of their employees.

Costs have continued to rise because provider organizations have been merging in order to gain more market negotiating power. Expensive patented drugs and medical devices also play a major role in driving up costs.

Ya insurers are price takers. They’re fine being the bad guy though—your employer picks them, not you.

It’s unpopular to point fingers at provider orgs.

> Until your problem costs us a lot, don't you dare try to mitigate it on our dime!

I assume gp meant bariatric surgeries by 'weight loss procedure'. These are not just cost considerations , they come with significant risks and long term side effects. They aren't get out jail free card to be handed out like candy and isn't a 'preventive care' for obesity related diseases.

No. I was literally charged full price just for consulting with my family doctor about my weight. The doctor at the time referred me to a nutritionist; the nutritionist coverage was further denied because I had no qualifying health conditions. There was another option for weight loss medication, not the kind that affects hormones but makes the stomach feel full. These were also denied because I was just fat, not diabetic, heart problem, etc.

yea you might be one of those 'overweight but metabolically healthy' people. Despite the common misconception, you can infact live a healthy life even you are overweight if you are metabolically healthy ( ie. no insulin resistance)

Perhaps they are, perhaps they aren't. But it seems to me that the way to figure out whether they are or are not is by taking the very reasonable step that they took: a visit to their GP (and including following the doctor's referral to a nutritionist).

Metabolic health is not the only type of issue overweight people face.

I suspect the real issue is that there are no universally proven ways to reduce weight that have high success rates of adherence - for example, this is why CPAP and insurance is really tricky... too many people wear them for a bit then stop using them, wasting thousands of dollars (between the sleep study and the equipment itself).

> This is such a stupid, self-defeating policy for an insurer.

Quick, rank speculation:

100% of obese people don't go on to suffer from 100% of the potential risks of obesity.

Given the actual percentages, it may be cheaper for the insurance company to pay for (and, at least in part, deny!) actual treatment for those potential risks than to cover the vast majority of preventative doctor visits and labs.

Additional rank speculation-- I wonder if that problem gets worse as obesity numbers rise. E.g., symptom A necessitates a test for condition X, but symptom A plus obesity necessitates tests for condition X, Y, and Z...

I'd be willing to bet that GP had a high deductible health plan. They leave you on the hook for 100% of your healthcare costs until you reach your deductible, unless your care is on a narrow list of things that they consider "preventable care." By insurer logic obesity is almost certainly an existing condition, even though treating it can prevent future healthcare complications. HDHP's are pretty perverse IMO.

How many pounds over a healthy weight were you? 20? 50? 150?

Just curious

Doesn't matter. I asked how significantly overweight I had to be to have access and the insurance company told me there's no weight-- it's purely obesity related health condition only. Theoretically also I could be 10 lbs overweight and diabetic and get a fast track to ozempic, lol.

At one point my family medicine guy suggested he could write down something arguable just to get me to a nutritionist (think making me do some wicked pose while measuring my blood pressure and then writing it down as "high blood pressure") and I told him just don't bother. We did however in future meetings ensure I always had something else to talk about besides my weight progress so I'd never get billed again.

They usually consider you for surgery if your bmi is over 40 and you've tried ( and failed) conservative approaches to weightloss.

No, that's not the case for many insurance companies. My insurance company only qualified surgery if you had a qualifying health condition. If you were just obese you didn't qualify.

The most serious health effects tend to come not from absolute weight per se, but from excessive body fat percentage. And particularly from visceral (intra-abdominal) fat, which is far more dangerous than subcutaneous fat in terms of risk for conditions like type-2 diabetes, arteriosclerosis, and COVID-19.

The excess adipose tissue causes subtle, progressive damage which won't necessarily be obvious in the regular preventative screening exams that most younger patients receive. But as some point after age 50 or so the systems decompensate and the patient's overall health deteriorates rapidly.

I received a lot of these services for free at the local health food store.

Offering nutrition advice at food stores is probably a better approach then doctors visits.

The number one problem is that a visit with a discussion costs $250 which is absolutely ridiculous, obscenely expensive.

Healthcare insists on the very best, most expensive in gauzes and then when they can’t afford them they let people die, instead of using cheaper gauzes which are just fine and have been used for years.

- Let’s go mountain biking!

- I’m uninsured. Too risky.

You could do something about that.

lack of insurance is stopping people from taking a walk around the block. It has to be a extreme sport.

Our built environment makes it difficult to walk anywhere. We should work on that.

I don’t see why not.

People who do vigorous sport can turn into complete couch potatoes once they are too old to practice that sport. Difficult concept for you to get, perhaps? Hint: being “healthy” wasn’t the point; it was the excitement, the adrenaline… etc.

I am obese, I have been fighting my weight nearly my entire life. At one point I did manage to get down to a "normal" weight and body fat percentage, but it took more than 7 years of concerted disciplined effort to do so, and it disappeared in less than 6 months by no longer eating as a significant calorie deficit, despite a massive increase in physical activity. For many obese people, for reasons we don't fully understand, our metabolism does not work the same as for people who are not obese.

The first time we've had any sort of medical intervention that seems to actually address this is the invention of GLP1 agonists and similar medications. Most insurance providers REFUSE to provide coverage for these medications, even though they are a net positive for the patient and society. Taking a GLP1 agonist while obese can straight-out /prevent/ the development of Type 2 Diabetes, even while you are still obese, and can cure some people of Type 2 Diabetes while they are ungoing further treatment.

I am very lucky in that my insurance does cover this treatment. The insurance of several of my friends (who are on ostensibly "better" plans because their premiums are more heavily covered by their employers) does not cover this. If I could make one legal change to the healthcare system in the US, it would be to require insurance providers to cover preventative treatments for obesity. Obesity is the primary cause of chronic health problems in the US, and it's nearly entirely preventable with proper care, but it's almost impossible to get that care /even as a tech worker with employer-provided insurance/.

It should be affordable and accessible for nearly anyone in the US to get access to GLP1 agonists and a dietitian. It isn't currently. Lacking this, means that obesity will continue to be a social disease that drives up healthcare costs and drives down productivity, quality of life, and total life outcomes in the US.

> For many obese people, for reasons we don't fully understand, our metabolism does not work the same as for people who are not obese.

My impression was that obese people first get less insulin sensitive over the years and then become obese as a result.

They usually measure insulin sensitivity as a proxy to 'metabolism'.

> It should be affordable and accessible for nearly anyone in the US to get access to GLP1 agonists and a dietitian.

I thought it was only approved for diabetes not obesity.

> I thought it was only approved for diabetes not obesity.

Ozempic and Wegovy are the same substance from the same company, Ozempic is approved for diabetes, Wegovy is approved for obesity. Similar situations apply to other competing GLP1 agonists.

oh yea i think i have some family on wegovy ( or maybe mounjaro now ), hadn't realized that it was approved for obesity.

What i don't understand is that you are saying these are "preventative treatments for obesity" . aren't preventative treatements given before the condition even comes into picture, these drugs are after you get obese so not sure how they are preventative.

Doesn't weight just come back instantly once you stop these drugs. Hard time accepting that solution is putting 200million americans on this drug for rest of their lives.

"Cardiometabolic improvements seen from week 0 to week 68 with semaglutide reverted towards baseline at week 120 for most variables."

https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.147...

I didn't say it prevents obesity, I said it prevents Type 2 Diabetes, which is a chronic disease caused by obesity. And it does. It's nearly a miracle drug.

Yes, if you stop taking the drugs, after a short time you return exactly how you were prior. You must take these drugs for life, unless something else comes out that improves the situation.

> it prevents Type 2 Diabetes

Ah I understand now what you meant. I remember looking into while ago( i have like half my extended family on these drugs now lol) but couldn't really find evidence to support this claim.

"There is only limited-quality evidence that at-risk patients taking GLP-1 receptor agonists are less likely to progress to diabetes (number needed to treat [NNT] = 23). Serious adverse events were more likely in patients taking GLP-1 receptor agonists than in patients taking placebo (number needed to harm [NNH] = 42). There is insufficient evidence to evaluate the effect of DPP-4 inhibitors on at-risk patients. There is no evidence that either medication class affects the development of diabetes-associated complications.1"

https://www.aafp.org/pubs/afp/issues/2018/0401/p437.html

Have you done a resting metabolic rate test to establish a baseline for total daily energy expenditure?

The GLP-1 drugs can be a net benefit for some patients but they come with serious side effects. In particular most patients lose significant amounts of lean muscle tissue, which is a risk factor for metabolic diseases and sarcopenia.

https://peterattiamd.com/ama45/

It's not clear to me that the risk to lean muscle tissue is unique to GLP-1 drugs. The counter point is that the risk exists in practically any severely calorie restricted plan. In other words, the reason why most treatments work is by reducing calories and if you reduce them too fast, any of those treatments will put lean body mass at risk.

When a patient loses weight, some fraction of that will always be lean muscle mass. The issue with GLP-1 drugs is that fraction tends to be higher than with other approaches to weight loss. See the link I posted above for details which should make the risk clear to you.

There are circumstances when those drugs are medically indicated. However, it seems they are being over prescribed without proper consideration of the harmful side effects.

The link doesn’t actually cover all the material listed, only the first 27 minutes. It looks like the relevant stuff came later.

Was that higher fraction compared to equally drastic calorie reduction in other methods in a RCT?

Basically yes, but there are nuances too complex to summarize in a brief comment here. If anyone is considering taking one of those drugs then I highly recommend subscribing to watch the entire video and read the show notes (including the linked scientific papers). There is a subscription fee but the it's a fraction of the price of the drugs and the information is top notch.

Can you link those articles directly? I have access to a lot of journal but it’s more out of curiosity than as a candidate for the drugs

This a purely anecdotal opinion but most people overestimate their required calorie intake, and according to my long experience in the fitness world you need to keep your desired weight stable for at least 2 years to reach homeostasis and avoid “rebound”. Increased physical activity has a lot of benefits but it has a mild impact in weight loss. Again, this is solely based in my 20+ years of experience.

> most people overestimate their required calorie intake

It's not something so mechanical as this. For obese people, our /bodies metabolic system/ overestimates our required calorie intake and causes us to feel the pangs of hunger far past when we've consumed a sufficient amount of calories. It's not a conscious choice to overeat, nor is it something that takes effort to do. I ate like a normal person while traveling around the world, walking 10 to 15 miles per day, and going to the gym 3 times a week for an hour, and I still gained back 40 pounds over the course of 18 months (nearly 20 of it in the first 6 months) after going off a monitored, strict calorie restrictive diet.

My actual daily caloric intake need was around 1200 kcals, exceeding this isn't hard to do, and keeping to it was a daily struggle that wasn't possible to maintain while traveling when I could no longer strictly control all the food I ate or even know how many calories it was or what its ingredients were. If I was to guestimate, I'd say I was consuming between 2500-3000 kcals daily while traveling, and this was sufficient to gain almost all of the weight I lost over 7 years back in a matter of months.

This is the reality of being obese. It's not like you choose to be fat, or you choose to over eat, or even that you're over eating to the point of gluttony, it's merely that your metabolism needs far less calories than it believes it needs, so if you simply eat a normal amount when you are hungry, you will be fat, guaranteed.

The reason GLP1 agonists work so well is that they actually change how your body's metabolism reacts, and make it so you no longer feel hungry constantly. In fact, you have to force yourself to eat sometimes or you'll end up having the effects on not eating often enough. While taking a GLP1 agonist, reducing or maintaining weight is not the same struggle as it is without medical intervention.

I counted calories and religiously recorded all of my physical activity and food and water intakes using very technological means tied into MyFitnessPal for almost a decade. It was not for lack of effort, dedication, or knowledge that I gained back weight or realized that I was not going to succeed for a lifetime without medical intervention. It's simply not possible to rationally fight your base biological impulses when they are fall into your body's basic survival mechanisms. I effectively "tortured" myself psychologically for almost a decade, and the net result was the moment I stopped I gained all the weight back. GLP1 agonists are basically miraculous.

If we are at "swapping anecdotes and wild speculation", getting the right medical diagnosis and improving my nutritional status caused me to unintentionally drop multiple dress sizes.

My hypothesis: Obese people are unknowingly malnourished and keep eating because they still need nutrients they aren't getting.

Maybe not just crazy talk given how nutritional value of produce has gone down in recent decades.

/pet theories

Hey mate, as a fellow obese (soon to only be overweight) person, I found something that makes a lot of sense to me: the carbohydrate-insulin model of obesity.

The thermodynamic model of calories-in-calories-out doesn't work because we are not a thermodynamic system; it doesn't take into account the hormonal and metabolic changes that occur when calories are chronically restricted.

> I was under the impression that USA healthcare has out of control costs due chronic diseases.

It's an incorrect impression. All health care systems have to deal with chronic diseases. Americans are fat, through they aren't twice as fat as other people, and the UK and Greece are nearly as fat in Europe. US health care costs are out of control because the system is kleptocratic.

> What can any healthcare system possibly do about that.

Its damned job. The healthcare system doesn't get to complain about the existence of sick people, even if people eugenically think that some illness are less deserving than others.

> through they aren't twice as fat as other people

Did a quick google search.

"The Health Survey for England 2021 estimates that 25.9% of adults in England are obese and a further 37.9% are overweight but not obese." 1

"Approximately 70% of American adults have obesity or overweight. " 2

1. https://commonslibrary.parliament.uk/research-briefings/sn03...

2. https://www.fda.gov/news-events/press-announcements/fda-appr...

> Americans are fat, through they aren't twice as fat as other people

They are, almost:

"US obesity prevalence was 41.9% in 2017 – March 2020"[0]

"25.9% of adults in England are obese"[1]

[0] https://www.cdc.gov/obesity/data/adult.html [1] https://commonslibrary.parliament.uk/research-briefings/sn03...

> I was under the impression that USA healthcare has out of control costs due chronic diseases

That certainly doesn't explain a great deal of it.

For me, my ability to stick to a diet was predicated on my ADHD being properly medicated. I never reached the "obese" category, mostly because ADHD seemingly doesn't prevent me from sticking to an exercise plan, but I was in the "overweight" for most of my 20s because I wasn't able to focus consistently enough to effectively count calories.

Many people can't stick to a diet or exercise plan because they haven't been treated for a related problem. For example, many people can't effectively exercise due to joint pain which could be alleviated by physical therapy which is frequently denied by health insurance.

Additionally, the "healthcare system" includes stuff like nutritional and exercise education, public gyms, etc., all of which are woefully underfunded in the US. Worse, the programs which do exist have been heavily influenced by lobbyists (lobbyist influence on the Food Pyramid, for example, is well-documented). The corporate right to lie in advertising also means that much education is undermined by straight up lies in ads.