Your Chocolate or Your Life? (Me, I’m Thinking It Over)

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(With apologies to Jack Benny.)

If you are autistic, or you’ve done any reading in depth about it, one thing you have probably heard of is the GFCF (gluten free, casein free) diet. That basically means no wheat or most other grains, and no dairy products. The theory is, firstly, that autistic people are congenitally unable to fully digest those foods, and that’s why we have so many Digestive Iss-Yews. Secondly, advocates of this diet say those foods function as “opiates” for us and thus make us more stuporous than we would otherwise be.

Me, I’m agnostic about it. If you feel better, or your autistic kid does better, eating that way — great. I’m not gonna shove pizza down anyone’s throat. However, it needs to be said that it’s likely most autistic people don’t actually follow this diet, at least not all the time; they (and/or their parents) don’t find it particularly useful or even especially sustainable to keep up. (I don’t think there’s ever been a study done of what the percentages are of autistic people following GFCF; my assumption is largely based on anecdata.) Joel Smith of the blog NTs are Weird believes that the “gut issues” associated with the autism spectrum are mostly about stress, rather than an inherent inability to digest certain foods, and given the ridiculous amount of stress most of us experience throughout our lives, it’s tough to argue with that.

However, Gut Issues are pretty much what I’m all about. I admit it — what I like to eat sometimes (okay, a lot of times) doesn’t like me back, and that fact doesn’t necessarily stop me from eating it again. And it doesn’t have to be “junk” food, either; sometimes a vegetarian meal of legumes and veggies and rice and flatbread that looks perfectly salubrious on paper goes through me like a tornado. This is where all the hatebags will probably descend on me screaming, “See? You fatties, you just eat whatever you want even if it fucks you up and you don’t care about MEEEEEEE and my bank account!” Here’s the problem, though. It’s a lot harder to pinpoint what does “fuck me up” when I eat it than to ascertain what doesn’t. If vegetables and salads do that to me, then it’s probably not just that I have a congenital inability to eat gluten and casein, yadig?

My shrink (who’s not autistic) told me that a couple of years ago, she was having Gut Issues herself. So she, following the advice of a nutritionist who believed in the “systemic candidiasis” gut theory, went on a dietary regime for two years that was not only gluten and casein free, but also low carb. (So much for being vegetarian on a diet like that, huh?) The idea was that those nasty yeasties would have nothing to yeasty-feast on and would eventually die off and go away. She was already quite thin and wasn’t interested in weight loss, and she did eat small amounts of potatoes, brown rice, and oatmeal, enough that she wouldn’t go into ketosis. And she ate as much protein, fat, and non-starchy vegetables as she wanted, lots and lots of each of those, so didn’t go hungry. And, she said, “My gut issues cleared right up.” She’s now back to eating much more omnivorously, with no problems.

Now, think about what a diet like that would consist of. Or, more to the point, think of everything you’d have to eliminate. Obvs, no baked goods, no fruit (!), no pasta, no white rice, probably no alcohol, no desserts — and most especially, no chocolate. For two years. Are your coffee beans broken? I can’t do that. Yeah, there’s an end in sight and I wouldn’t have to do it forever, but would it feel that way? Besides, how do you stick to something like that and never fall off? I don’t have a lot of confidence that there wouldn’t be recidivism, especially living with two skinny men (one an extremely active 18-year-old) who heart their carbs and would be very cranky not having them in the house unless it was a matter of life and death for me, or at least a matter of my being able to work versus not being able to.

I asked her, “Weren’t you depressed eating that way?” I remembered reading Geneen Roth’s Appetites, which was centered around Roth’s experiences with a “Candida diet,” and Roth basically said the diet didn’t do anything but piss her off and screw up everything she’d managed to learn about intuitive eating. Being someone with a history of major depression — not to mention someone who has binged pretty fiercely after restrictive diets — this was not an idle concern for me.

“At first I was,” she admitted. “But after a while I felt so much better.”
She did say that if I decided to do this, I shouldn’t do it on my own, but that I should work with a GI specialist and a dietitian (or naturopath) who knew what they were doing.

When there’s something you really, really want and don’t have, it’s easy to be vulnerable to the claims of people who say they have the Instant Cure. Part of me kept saying, “Oh hell no, I can NOT do that. There’s no way.” And another part of me says, “You’re not going to get to eat everything you want forever, everyone has dietary restrictions if they live long enough, so get over it.” And with me, of course, all of this feeds into normalcy pangs. Don’t you want a group of real friends, living right here in town, to hang out with every week? Don’t you want less gas and not having to spend so much time in the john? Don’t you want a real career? Is chocolate and all those other things worth sacrificing all that for? Think of all the friends you’ll have if you give up carbs! Women love talking about what they’re not supposed to eat! You will be One of Them at last!

Yeah. And I’ll also be living alone because I will have driven my partner irretrievably bonkers. Thanks for playing.

And this isn’t even a “diet” in the weight-loss sense. There’s no getting on a scale or whipping out the measuring tape to see if I’m doing it right. And once it’s done, it’s done; once the two years are up, I can start phasing all those foods I love back in gradually, and life will go on. There’s no going to bed hungry. There’s no getting clipped about the head by a “counselor” who’s pissed at me for cheating with cough drops. Only one thing is important: Do I feel and function better eating this way?

And yet, even this much seems overwhelming to me. Not to mention objectionable in other ways; I would probably have to eat a whole lot more meat than I’m eating now, and I don’t particularly want to do that. I feel guilty enough eating the amount of it that I do, and haven’t ruled out becoming a vegetarian again. And isn’t it true that once you haven’t eaten something for a while, you lose your ability to digest it? What if something looks or smells so good I can’t resist, and by then I don’t have the enzymes to digest it anymore? Won’t that make me seriously sick, much sicker than I am now?

On the other hand, I feel like I’m so weak for not feeling capable of doing this, for being such a slave to my appetites and cravings that I won’t give up anything I love, even if it would help me. I feel like maybe people are right to discriminate against my fat ass, that their perception of me as weak-willed and self-destructive simply by dint of my body shape is accurate. Sacrifice? Hard work? Stiff-upper-lip attitude? Strike one, strike two, strike three. Yeah, it’s true. “My chocolate or my life” doesn’t sound like much of a choice, and I’m not even eating a lot of chocolate or eating it every day. Even doing one of those things — no gluten, no casein, OR low carb — seems like a recipe for feeling mentally lousy, even if it’s time-limited. What if I do have medically related dietary restrictions one day? Am I going to be one of those people who’s chronically noncompliant?

I guess I have some thinking to do. Now, if you’ll excuse me, I have an overripe banana to eat.

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What Does Health Care Reform Really Mean to American Fatasses? Conclusion: How Expensive Am I Really?

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The first four parts of the series are here, here, here, and here.

First, I want to thank everyone who’s participated in the discussions here. Even those of you I disagree with on this subject. I’m really impressed by the level of discourse here and by everyone’s willingness to share their experience and insight.

I said in my first post that I was going to talk about the “let them eat emergency rooms” meme, but as it turns out, Dr. Pattie Thomas of Fattypattie’s did it better than I could, here and here. (And in case I’ve never said it, Pattie Thomas just kind of rules in general.) YEAH about the complete waste of resources involved in making people go to emergency rooms for nonemergency care (including the spread of communicable illness, some of it extremely debilitating, from people waiting for hours in an ER lobby), just because ERs can’t ask patients for payment in advance. Contrary to popular belief, though, they certainly do get billed — and how. Like Pattie says, price gouging (e.g. charging $15 for two aspirins that probably cost hospitals less than a penny each) is the name of the game; they figure that if they keep presenting outrageous bills to people, someone will cough up and thus make up for all of those who stiff them. Thus, health care expenses get easily conflated with health care costs.

Which leads me into all the BS I’ve seen lately (I don’t even know how to begin where to link, there’s so much) about how Americans are so costly to treat because we’re such bad little girls and boys (and intersexed kids) who put all kinds of naughty things in our mouths even after our parents (i.e. the superslim health-food el33t) told us a million times not to or we’d be punished but good. Shit, even parents of 2-year-olds manage to put plugs in the light sockets to prevent their little darlings from electrocuting themselves; if they’re going to treat us like children, they might as well go all the way and ban all those things we’re not supposed to be having. Seriously, if two-thirds of us are being smothered to death by our fat, and the foods we eat are drugs of abuse for a substantial majority of the population, why aren’t they banned? Putting out cooked food in front of hungry, tired people and expecting them not to partake because they want to be Goody Goody Good just sounds kind of…I’d say interplanetary, but I suspect even creatures from other planets would think we had flipped.

Part of the reason why, of course, is because if people only ate and drank what they needed to for base survival, our economy would go into the shitter and never come out. They might not want us eating “excess food” but they sure as hell want us buying it. But the other reason is that nobody can especially agree on what everybody “should” be eating for their health. The Atkins-heads and the vegans can’t both be right that their diet is optimal for everyone. Nuts are great, unless you have diverticular disease. Leafy greens rule, unless you have to limit your vitamin K intake because you’re on blood thinners or phlebotomy treatments. Spinach rawks, only don’t touch the stuff (especially if it’s double-cooked) if you have a history of kidney stones. Tofu and soy protein? Fabulous, unless you have to avoid soy isoflavones because they mess up your hormones. And of course, we all know about all the mercury in the fish and the hormones in the chicken and the beef, unless we spend a squillion dollars a pound for the untainted stuff or grow it ourselves on our own private farms. Not to mention all the people who have illnesses and disabilities for whom cooking a “good wholesome meal,” especially day in and day out, would just use up all their spoons and make them feel worse. As Barry Glassner said, “A diet that is harmful to one person may be consumed with impunity by another.”

But let’s imagine, just for a few seconds, that we could come to a consensus about what constitutes healthy-diet-for-most and healthy-exercise-for-most. Let’s make it even more fun and make Michael Pollan and Alice Waters the supreme arbiters of what almost-everyone should eat and how almost-everyone should spend their leisure time. Since everyone in their world has plenty of leisure time, let’s imagine everyone else will be given the same gift, of not having to work more than 35 hours a week to cover basic expenses, and will at the same time have their food budgets increased to the point where they can afford the very best of everything. (Oh, what the heck, let’s throw in enough of a housing budget so everyone will live in California and have a year-round vegetable garden, too, since we’re playing with Monopoly scratch and it’s a really BIG state that should easily accommodate a population of 300 million and counting. No? Too much? Michael and Alice have that, and we’re playing that everyone has to live like they do, and they couldn’t do it in North Dakota in January. I dare them to try.) Oh, and while we’re at it, we will rezone everything so that everyone can walk or bike to work (assuming the universal physical ability to do so with a belly full of healthy grub, since they assume that).

Does anyone have any freaking idea how expensive that’s going to be?

Not, mind you, that I think it’s a bad idea for everyone to have that much leisure time and that much great food and that much sunshine and fabulous topsoil. If nothing else, the reduction in stress would be a boon to people’s mental health, and we know that mental health impacts physical health, and both mental and physical health count towards health-care expenses, not to mention overall quality of life. But you can build all the sidewalks you want, and it’s not going to matter unless people can work a lot less and a lot less hard to get by. You can build all the public parks you want to compete with McDonald’s Playlands, and it’s not going to matter if people don’t feel safe going there or letting their kids go there. (Not to mention the fact that if you’re a kid who’s been hassled even once for your weight on a public playground — and what fat kid hasn’t? — you’re not going to want to go back there unless you’re forced to. So without ratcheting down the fatphobia in society by a lot, there aren’t going to be a lot of fat kids playing outdoors.)

Furthermore, none of that stuff is going to make the vast majority of people go from “obese” to “not obese,” unless their “obesity” was very borderline to begin with. (It’s also not going to prevent “not obese” people from becoming “obese” unless you’re also going to outlaw being on a diet in fourth grade like half of all 9-year-old girls are, which I could actually go for, AND also outlaw all medications that have weight gain as a side effect, which I couldn’t, while simultaneously finding a safe and effective cure for congenital insulin resistance. And maybe we’d better throw in a little gene splicing, too, while we’re at it.) And as we know, those of us who believe in HAES are still considered kooks, so once five years have gone by and almost everyone who was fat before is still fat, one of two things happens: They give up, figuring they’ve wasted enough money already, or they do it harder (as in forcing people to exercise harder and harder and eat barrels full of veggies and less and less of everything else). I can only guess which direction they’ll go in.

Either way, it’s going to be unbelievably very extremely scary expensive to do all that for absolutely every American. (Not to mention that preventative care, which we’d presumably be getting a lot more of if we get more people covered, makes people live longer. A longer life is almost always a more expensive life.) We might be able to evolve that way over a century, save for the moving-everyone-to-California part, but those of us who are middle-aged now won’t likely live to see it. They’re going to have to deal with our flawed bodies and our nasty habits the way they are, seeing as we’ll be entering our Medicare years dealing with the sequelae, such as they are, of both. (And if you’d told me in high school that drinking a milkshake would one day be considered the self-destructo-equivalent of freebasing, I’d have thought you were having a pretty good freebase hallucination yourself.)

And speaking of which, I love how we’re simultaneously told that we big fatty mcwhaleypantses won’t live to see our 70th birthdays and that we are also going to bankrupt Medicare in ways we would not if we switched bodies (and by implication, personal habits) with our slimmer (and allegedly much longer-lived) peers. So which is it? Am I going to live long enough to clean out the treasury, or aren’t I? To be honest with you, I don’t much care if I do or not. I don’t even know if I could deal with having chemo and radiation without having a total meltdown, let alone deal with people sticking instruments into me all day long while simultaneously not being able to have kitty cats around or wake up and see my sweetie’s sweet face, and all the healthy habits on earth aren’t going to guarantee that I won’t end up that way eventually. I once did data entry of patient-care info as a temp for a nursing home, and I swear some of the machinations they had to put people through to get a few grams of crap out of them were unbelievable. Give Dulcolax, and if Dulcolax doesn’t work, try more Dulcolax. If more Dulcolax doesn’t work, try a Fleet’s enema. If the Fleet’s enema doesn’t work, try a suppository with a lighted fuse on the end of it. And get catheterized urine samples too while you’re at it. ARRRGH. I bet I’d be a very bad autie under those circumstances.

What I do care about is, am I going to have the foundation ripped out from under me in the next 20 years, in a way that will shorten my life enough that I’ll never even see a Medicare card with my name on it? Because that’s a very real possibility. I know that my current state of mental health is an incredible gift; annoying medication side effects (and potential long-term sequelae thereof) notwithstanding, after a year of treatment I don’t even think of suicide at all anymore. The last time it happened, and it was so long ago I can’t even remember when, I was able to brush the thought away within minutes. I can actually work, albeit at a job where they tolerate my eccentric work habits and schedule. And it can all be taken away from me with a finger snap, if the drugs stop working and I can no longer work, or if someone decides that I’m getting too many perks and decides to slash my coverage. That kind of stress, of always being aware of the shark tank beneath my tightrope, can’t be good for my health, for any part of my body. Killing people — which a health care system that only covers the healthiest Americans inevitably will do more of — certainly makes them less “expensive.” But we want it both ways. We want everyone to live to be 95 years old and productive and happy and active right up to their last breath — and we also want to save money. And we think we can do all that by everyone being enough of a goody-goody that we’ll all just peacefully expire in our sleep, after having spent 30 years needing almost nothing in the way of drugs, hospitalizations, or surgeries. But bodies are expensive. Any bodies. The sooner America figures that out, the better.

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Reply from Sandy to My Last Post

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Sandy from Junkfood Science just posted a long reply to my last post; since the thread had died by then, I thought I’d put it up top, because there are some issues she brings up that I wanted to tackle (and give other people a chance to also). This is the post in its entirety:

Arguments based on the past are irrelevant when we’re discussing healthcare REFORM. For everyone’s sake, the fat community desperately needs to understand the reality of what is being planned and put into place, the complete picture and consequences, and understand what words (like ‘quality’ of care) actually mean — not get caught up in what they’d like to see happen or what they think is right. Nor can anyone afford to believe media, anecdotes and social marketing. (RWJF interests, for example, have widely infiltrated online communities.)

The noncompliance examples given are spurious. What will label doctors noncompliant are pay-for-performance measures — those clinical guidelines and performance measures that make money for stakeholders (i.e. pharma). The medical literature has well documented that most all of these P4P measures are unsound and don’t actually improve patient outcomes or lower costs (and are all too often to the detriment of certain patients), yet the interests beind them have imbedded themselves in every level of the HHS and the CDC (see July 30th post). Under government managed care, the numbers of P4P measures have exploded and the consequences for doctors who fail to comply with them are steadily becoming more severe. Doctors who don’t do what the government says, already find their livelihood and licensure jeopardized (failure to comply is already on a schedule of increasing pay cuts, and negative ratings on their practices). Electronic medical records that are being required of every Medicaid/Medicare provider are being set up to monitor their compliance to P4P measures (tests ordered, prescriptions written, etc.) which will determine their pay, and automatically report their patients’s (our) medical information to the government to identify those for case management by government/insurance company. Medicare already pays doctors and hospitals 20-30% less than comparables, Medicaid pays 30-40% less, meaning fewer doctors and hospitals can afford to care for the poor. More importantly, out of necessity, care is restricted to what the government will cover.

Compounding the discrimination, they aim to pay doctors based on patient outcomes –- which means if you are fat or have a chronic disease and your health indices don’t meet guidelines, your doctor will receive less reimbursement –- doctors won’t be able to afford to take care of these patients and the patients will have increasing difficulty finding a doctor practice to accept them. Under their planned medical home model of government managed care, however, we won’t have the ability to just go to see any doctor to get the care we want. Instead, you’ll get the cheapest care because you’re costing the practice and hospital. Politicians are also looking at some troubling ways to ‘incentivize’ compliance among patients, calling it tough love. Look at what already happened to poor mothers on Medicaid in increasing places — noncompliance with healthy lifestyles contracts means no more government assistance or additional subsidized care needed for their special needs babies. There is nothing moral or compassionate about third-party health management.

You really don’t want your doctor having to answer to a third party payer (the government or government insurance plan), rather than provide the care he/she feels is best for you (especially if you are fat, aging, poor or have a disability). That also goes against every tenet of medical ethics. It’s why so many doctors and nurses have and will leave the profession rather than be forced to do that. Their conscience won’t let them be shills for pharmaceutical companies and political stakeholders or, worse, have to participate in things they know will hurt people.

Stakeholders are promoting bariatrics and weight loss interventions as saving the system money (while actually making THEM money) — they are not interested in the efficacy (soundness of the scientific evidence), long-range complications and deaths. Fat people are seen as undesirables in the prejudicial visions they have for a healthy perfect populace. But, the public largely believes obesity is a person’s fault and the obesity industry realized years ago that the public wouldn’t support paying for weight loss interventions for fat people – that’s why those same interests starting making it about their ‘health’ and turning to ‘obesity-related’ health indices, with a pill and lifestyle intervention for each. Another example of the need to understand what is going on: Did you know they are already eliminating funding for repeat hospitalizations for complications from the same diagnosis for all patients under government healthcare (Medicare/Medicaid)? This most affects elderly, about 20% of whom are rehospitalized after a medical incident due to complications. (And bariatric patients, of course.) Talking with ICU nurses last weekend, they were in tears because they saw that they were going to have to turn people away or give minimal care because the hospital was facing being unable to afford to provide it free and without compensation. And the hospital had already cut staffing, especially of the most experienced medical professionals, and they were being worked to death with mandatory overtime.

The most significant consequence of the clinical guidelines and pay for performance guidelines under managed care will be denying subsidized care to fat people who haven’t lost weight, to the disabled and to seniors; or providing suboptimum care. Such people are being said to be burdens on the system and not cost effective to expend much money on, under the comparative analysis method they are planning to use to prioritize healthcare spending. You need to understand how healthcare spending is planning to be allotted.

Most important: You are confusing health COVERAGE with heathCARE. As Big Liberty said, what will happen is that fat people and seniors who need care beyond the government’s free basic coverage, will have to find a way to pay for it themselves or suffer. Discrimination can be disguised as equitable.

The best hope for fat people and everyone getting older is a system that allows as many choices of plans and care providers as possible. Not one where the government eliminates their options.

First, Sandy, thanks for stopping by.

But I do think the past (especially the recent past) with regards to UHC is very relevant. You’re trying to tell us that we’re going to be the only country on the face of the earth where, if UHC is implemented, Big Brother is going to force us to live on plain broccoli and work out five hours a day and we’d better like it, when even current forms of U.S. government-sponsored health care, by all indications, are NOT like that. I have recent experience working at a VA Hospital; I did their medical records. Believe me, if they were only treating total goody-two-shoes whose abs you could bounce dimes off of, they wouldn’t treat anybody.

Also, all the problems you mentioned about third-party interference in care are going on right now. You’ve even written about it yourself! American doctors right now are experiencing more and more bean-counter interference from third parties (i.e. insurance companies). People kill themselves because they can’t get care approved by the bean counters.

This American for-profit health care wonderland where nobody interferes with individual doctor-patient decisions, and those decisions are always made in the patient’s best interests, doesn’t exist. (Just ask anyone who’s tried to get a birth control pill or Plan B scrip filled in the Bible Belt.) In fact, it’s likely it never really has; in the pre-HMO days, we (especially us hysterical wimmenz!) had to worry about sleazy doctors and hospitals goading us into accepting medically unnecessary surgeries and other treatments to line their pockets; now, in the name of preserving the ludicrously overprivileged lifestyle of insurance company executives, we are told that the care we’ve paid all our lives for might not be there at all when we need it, and that that’s just the way it is.

You (and also Big Liberty) seem to think all we need to do to get everyone completely covered without bean-counter interference is to allow everyone to purchase policies from out of state. Maybe I’m dense, in fact that’s probably a given, but maybe at least one of you could explain to me how that prevents the sort of rescission and cherry-picking or excluding coverage for preexisting conditions that we’re seeing now, and won’t lead to even more price-gouging and the sale of completely worthless junk policies from fly-by-night companies.

This rescission shit is serious. It’s not to be taken flippantly. Insurance companies actually have rescission quotas, a certain number of policies they have to find (or make up) a reason to kill each month in order to stay profitable. And if you’re on a group policy, they can slap surcharges on your company for your treatment so huge they have no choice but to either scrape together some reason to fire you, or sharply reduce coverage for everyone to make up for the surcharge. I worked for one company which, over a five-year-period, switched carriers four times, and finally wound up offering pretty much a total junk policy that would have cost so much out of pocket it wouldn’t have been worth signing up for. That’s what we poor old disabled fatties you claim to be beating the anti-UHC drum for are facing here, being totally fucked between now and Medicare.

Right now I have what I’d say is B-minus to C-plus coverage. I know it could be worse, and with trends in this country the way they are, and having experienced what I have, I can ill-afford to be smug about it. So what happens to me, someone who is increasingly difficult to employ because of size, age, and multiple disabilities, and isn’t eligible for state-run care or Medicaid, if my company lays me off, or drops or guts our coverage, and I can’t hook on anywhere that offers something better because this gutted care has become industry standard and everyone thinks I’m too high-maintenance? You think the free market will take care of me? How, when all carriers’ entire business, their whole reason for being, is set up to avoid people like me whenever possible?

OK, readers, I open the floor to you. (And once again, please stay on topic; I don’t want this thread to become open season on Sandy. As we used to say in “program,” principles before personalities.)

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What Does Health Care Reform Really Mean to American Fatasses? Part 3: Fat and Compliance

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Part 1 is here.

Part 2 is here.

And thanks to Michelle for getting the ball rolling on the subject of “compliance” — that is, Following Doctors’ Orders (or else?).

In America (and I’m guessing most other countries too?), nobody is required by any law to do exactly what doctors tell them to do. Hell, nobody even has to see a doctor in the first place if they don’t want to, even if it means they’re delaying getting a problem checked out that will be more expensive to treat if they wait. And without violating any HIPAA regulations, I can tell you flat out after many years of creating medical records that people refuse recommended treatments all the time. I do a lot of ER reports, and the following scenario is extremely common: Patient presents to the emergency department. Doctor thinks patient should stay and have some tests run, maybe have some IV antibiotics or other medications. Patient says sie wants to go home. Doctor tells patient sie really should stay, and that sie runs the risk of dying or becoming much sicker if sie leaves. But patient is still permitted to sign out AMA (against medical advice) and go home if sie wishes.

And what do you think doctors tell patients when they do sign out AMA? “Okay, but don’t come back again if you get really sick, because you didn’t listen to me”? No. They say, “Return to the emergency department if there are any problems.” Because it would be completely ludicrous for them to say, “Well, asshole, you had your chance at proper medical treatment and you blew it,” right?

And yet, that’s what frequently happens to fat people who seek medical attention. They’re “ordered” to lose weight, more often than not they either fail to do so or gain back whatever they do manage to lose, and they’re told, “I can’t do a thing for you unless you lose all the weight I told you to lose and keep it off.” You’d think by now that more of them would get a clue that almost no one loses 50 or 75 or 100 or more pounds permanently through diet and exercise alone — except possibly for a few people who start out being extreme binge eaters and/or binge drinkers and don’t have a long dieting history, or who have made getting and staying thin their full-time job and never EVER cave in and eat anything “bad” or miss their two-hour (or longer) daily workouts even with the most wracking knee injury or virulent case of bubonic-boogie flu. And that’s just not reality for most of us. But the idea that most people have limited control over their weight hasn’t gained a whole lot of traction yet despite the staggering pile of evidence in its favor.

So we fatasses who remain fat — i.e. almost all of us — constantly run the risk of being labeled “noncompliant” by our doctors just because we exist. And the vast buttinsky contingent that exists here (though not, of course, exclusively here) just loves to bleat about how expensive we are compared to them because of our stubborn “refusal” to slim down. (Although I note with more than slight puzzlement that these are usually the exact same people who think their perfect habits are going to carry them through to their 100th birthdays — exactly how is it “inexpensive” to your fellow Americans to live to be 100?) They love to say things like, “Well, if you’re not following doctors’ orders, you deserve to have to wait your turn behind those of us who are trying to be good.”

To which I always say something like this: “If you’re going to rank people as a lower priority for care because of not following doctors’ orders, what on earth makes you think you won’t be next?

I’m one of those radical fruitcakes who thinks “imperfect” people deserve health care just as much as the Goody-Twelve-Shoes Club does. Because let’s face it, even the Goody-Twelve-Shoes Club has people in it who have pasts. How can anyone know that those 10 years of chain-smoking, or hard drinking or drug abuse, won’t come back to haunt them later? I and my fat ass never did any of that, so nyaah, all you smug former party animals. The GTS Club thinks it’s reserving its bared fangs and spittly hissing for people who are still doing those things right now, but believe me, the people who used to do that stuff won’t be far behind if we start holding out on people for being “bad.”

Michelle’s post was about a doctor who was having a hissy-pissy because his dialysis patients were drinking water when they were thirsty against his orders. Yeah, that’s all it took to bend his antlers; he talks about them “chugging gallons of milk or juice” at home, but I’ll bet my next Hot Lips fruit soda that the offending amounts of liquid were much smaller than that. (The comments on that post are terrific too; highly recommended reading.) So he wants all patients to do exactly what their doctors tell them to do, and no backtalk? He really wants to go there? It got me thinking about a whole pile of potential behaviors, none of them especially outrageous, that could possibly get a patient labeled “noncompliant” under a system that makes “good behavior” a prerequisite for care:

- Smoking pot. (It always astounds me how many pot smokers who don’t smoke tobacco think the smoking-is-noncompliance stick will never be used on them. With THIS government? Hah.)

- Not wearing your compression stockings when it’s 100 degrees out and the air conditioner is busted.

- Eating something that’s not on your 1800-calorie diabetic, soft foods only, no seeds, 2 grams sodium, low cholesterol, low residue, low fat, low oxalate, low protein diet. (Yes, people are actually given diets that ridiculous to follow at home.)

- If female, not having children young so as to ward off postmenopausal breast cancer.

- Staying coupled to someone who keeps flaking on you when you need to be driven to and from appointments.

- Self-discontinuing a medication because you don’t like the side effects, or not filling a prescription because you don’t feel comfortable taking that drug, or forgetting to take the drug as scheduled.

- Not having mammograms or prostate exams or colonoscopies or DEXA scans (for bone mineral density) as often as your doctor recommends, for any reason.

- Playing with or helping out the kids or grandkids when the doctor has told you to rest.

I’m sure you can think of others.

Heck, I even think people who do stuff I personally find objectionable — like screwing around in the car instead of watching the road and getting into an accident, or yelling at their employees to the point of making them come down with stress-related illness — shouldn’t get down-triaged for care. Because people aren’t perfect, and no amount of withdrawing care is going to make them so.

But let’s get real. We’re never, ever going to have a health care system in America where everyone pays and only the GTS Club gets full care. Because in case nobody’s noticed, this country, more than any other, is crawling with celebrities and other wealthy people. Many of these people don’t have the world’s most perfect health habits, or aren’t what doctors would consider “ideal” weight. Can you imagine an NFL linebacker being refused care for being too hefty? I can’t. Sure, do that knee replacement on him! It’s not like he’ll beat up on it tackling people for a living or anything. And if they don’t consider him to be a waste of a perfectly good prosthesis, there’s no reason *I* should be if I ever wind up needing it, when all I’m going to do is walk on it.

Chain-smoking movie stars? Alcoholic rock stars? No problem, they can hop right on in. There’s no way on earth they won’t be able to, even under UHC. And there’s no way on earth they’ll be told, “Quit right now, or no health care for you.” If they ever were, they’d scream bloody murder. If Michael Jackson could find one doctor to remove his entire nose and another to give him fucking propofol to use at home (something no mere mortal would ever, ever be allowed to leave a hospital with), there’s probably no limit to what you could find a health care provider to do if you’ve got the scratch. Yeah, they’re really going to outlaw all that stuff here and enforce all those laws to the letter when they’re already not enforcing laws that already exist. And I’m Malibu freaking Barbie.

That’s why I’m not putting a lot of stock in the idea that under UHC, we fatasses are all going to be “ordered” to lose lots of weight for good, no matter what it takes, or not get care. As it stands right now, they’re saving buckets of dough by millions of us never going to doctors because we’re not allowed to or can’t take the abuse. Can you imagine the expense of having WLS performed on every single “obese” person? And all the followup care? It would make all our current “fat related health care expenses” look like Slurpee money. (Not to mention the fact that Shaq et al would just refuse.) There are about 300 million of us, and they can’t even prevent all the convenience store owners from selling cigarettes to 13-year-olds in a country this size, even with a federal law in place prohibiting it, because it would be too expensive to crack down on all of them round the clock. If the idea is to make everyone “compliant” to save money, they don’t even want to know how much that’s gonna cost them.

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