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

meowser-48.jpg posted by meowser

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

  1. sannanina Says:


    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.

    You would be correct that this is the case in other countries, too, independent of if these countries have a universal healthcare system of some sort or not (I have got personal experience in Germany and in the Netherlands – but I am pretty sure this is the case in other countries too). Also, I really don’t know much about law, but I really cannot imagine how a law requiring people to follow doctors’ orders to get medical treatment would be compatible with the US constitution or pretty much any other constitution of a democratic country – and my mum who has much more knowledge in this area agrees with me.

    Can I just say how screwed considering not losing weight as non-compliance is, particularly in the light of how many health professionals seem to interpret non-complicance?
    First of all, it is illogical – weight loss in itself is not a behavior, but at best the result of a behavior. Non-compliance is when you don’t follow a recommended behavior, not if your body doesn’t conform to a physical change. Surely even the most fatphobic doctor has enough knowledge of human biology to know that the correlation between physical change and behavior is never ever 1 (that is, the change resulting from a given behavior differs between individuals)?
    Secondly, if a whole group of people shows low complicance it would be reasonable to assume that there is something else going on than that these members are simply stupid or lazy – for example, if a high percentage of people with condition X refuse to take medication Y to treat it that usually means that medicaiton Y has a very negative impact on people’s quality of life, and this is what it should be all about in the end – quality of life.
    And finally – as someone who has an inherently a very strong need to please people (and therefore to “comply”) I can tell you that having a doctor consider me non-compliant because I “stubbornly refuse” to lose weight really screws with my anxiety levels – and not just during a doctor’s appointment. How exactly is that good for my health? (Incidentally, this is one of the reasons why I loved a therapist I had a few years ago – she told me that she considered total compliance a problem.)

    • living400lbs Says:

      weight loss in itself is not a behavior, but at best the result of a behavior.

      Oh, but see, in order to be really really fat, we must be eating huge, seriously HUGE, amounts of food every day. Anyone who is noticeably fat MUST doing it deliberately, in defiance of normal people. If we just stopped feeding our faces for a day and went for a walk? We’d lose weight. We just have to stop stuffing our faces for, you know, a few hours.

      At least, that’s what the commenters on my blog tell me.

  2. vesta44 Says:

    The cost of forcing compliance to ordered weight loss would definitely bankrupt the government, so the fat-phobes can scream all they want about us wasting health care dollars, but once they see what it would really cost to try and force 300 million people to become thin, they’d pass out from the shock (the cost of WLS alone for that many people would run around $7,500,000,000,000 – not to mention all the follow-up care for all of the many complications that result from it).

    • living400lbs Says:

      It’s more likely that they’d “rediscover” that the “overweight” people aren’t very, and live longer anyway, and then declare victory because if you switch the “overweight” category into “healthy” then over 2/3rds the country is “healthy”.

  3. Trabb's Boy Says:

    I agree that compliance would not be forced with universal health care any more than it is now. If that were legal, insurance companies have a greater incentive to do it than the government. There probably would be an upswing in fat hatred generally, as more people will start to feel entitled to complain about “unhealthy” behaviour as costing them tax dollars. Oh, goody.

    BTW, any idea what happened to Sandy Szwarc over at Junkfood Science? There was no site on the internet I respected more for it’s hard science approach to health policy, but now she’s become really unscientific over universal health care. Her current article essentially claims the government will install cameras in our homes to ensure healthy behaviour, citing a British program dealing with child abuse situations and some anti-abortion group websites. Very strange.

  4. Lori Says:

    Thank you for this. I think the other issue, in terms of people being “forced” to lose weight or denied treatment, is that many doctors would simply not accept such a system. Yes, there are many, many asshole doctors out there who are terrible to fat people. But, there are also many who aren’t. There are also many fat doctors, and fat nurses, and fat physician’s assistants, and fat people working in all realms of medical care who would not sit by while fat people were turned away for treatment (as well as many thin medical professionals who would do the same). I’ve been very fortunate, but I’ve never had a doctor be anything but kind and respectful to me, and not make my weight an issue. I honestly cannot believe that any of them would accept a system where they were supposed to deny me care until I lost 30 pounds. I just don’t see any possible scenario in which I would have been told, “Sorry, I’m not going to treat your panic disorder until your BMI is 25” or “You shouldn’t have gotten pregnant when you were fat, so now you don’t get prenatal care” just because we had UHC, or where my health care providers would have accepted such a system.

  5. Lori Says:

    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.

    Just to add, am I an idiot for thinking that, since there is absolutely no evidence that this happens currently under government-funded healthcare (in the US), we don’t need to worry about it happening in the future? I do think, personally, that there are issues with trying to get costs to a minimum before getting everybody into the system, but I just don’t see any reason to assume that fat people (or anybody else) would be denied care for non-compliance. Plus, it already happens. I had a friend who, under her very good insurance plan (she’s a professor), was told by a neurologist that he would not consider ANY other causes for a condition she had than her being overweight, and refused to do anything for her until she came back weighing 150 lbs. Luckily she was able to see another doctor, who got her off of birth control pills, and her condition cleared up right away. But, this kind of thing already happens with private insurance, at the level of individual doctors. At least in a publicly-funded system, there might be more guidelines in place to STOP doctors from doing this sort of thing.

  6. buttercup Says:

    My biggest “doctor’s office” fear (HA, a pun) was being labeled noncompliant because it was always stressed to be a Good Patient and do what the doctor says. Then I learned to ask questions and expect answers. Then I found FA and resources on actually giving information to doctors that maybe they didn’t know. Then I found my current awesome doctor.

    My doctor is a fairly new one. I think she’s probably been in practice less than five years so her training is pretty fresh and she is unbelievably fat-friendly. And she listens.

    All the years I was a fat smoker with asthma I was never denied treatment. I got “you know you should quit, right?” and I admitted that I knew I should quit but that I couldn’t at that time. Most doctors were of the “you have to be ready” persuasion on that so I didn’t get denied care or treated like a big dumbass even when I came in pretty much unable to walk more than a half a block because I couldn’t breathe. So I don’t imagine my care would be that much worse as a “noncompliant” fattie even without the awesome doctor.

    (It’s worth noting that one doctor actually told me I should not quit smoking because it would make me gain weight. Seriously. This was maybe 15 years ago. Needless to say I did not see her again.)

  7. bigliberty Says:

    Thanks for this post. I have to disagree that the government would predominantly rely on financial disincentives to forcing a politically unpopular group to do something — there are a lot of moral crusaders who don’t really care about the price tag, if they get to carry out their moral crusade, or scapegoat an unpopular group for votes.

    But in my opinion, that would be a moot point, anyway. Because I don’t think there really are going to be government-sponsored weight loss plans, or government-supported WLS (with the exception of “extreme” cases). I think that it would be the same smoke blown at us for years — “Don’t come back until you’ve lost 100 pounds” — with no support, direction, or financial help to lose that weight (not that one should, anyway).

    What is more likely to happen is simply denying certain kinds of care until one is “compliant,” or disallowing someone to participate in benefits that thin people get (like adoption, for instance), with no offer of help or recourse with the exception of a consultation with someone who gives you a calories in = calories out lecture.

    The best way to determine what might happen to fat people as a group of healthcare consumers is to investigate what goes on in other countries with public options or single-payer systems. I remain unconvinced that fat people will be denied benefits offered to thinner people, or will have certain rights (parental, for instance) infringed on.

    Respectfully, while there are certainly problems with the system as it stands now with respect to fat people (and many other groups), I think a public option or single-payer system would only raise costs, reduce choice, and infringe on the rights and benefits of certain groups deemed to be too “costly,” “unworthy,” etc. I believe that moving towards a system that encourages more competition (allowing individuals to buy plans across state lines, as the first of many examples) would be the wake-up call that the insurance companies (and state regulators) need to open up current plans to more options and hence lower-priced alternative.

  8. bigliberty Says:


    “I remain unconvinced that fat people will be denied benefits offered to thinner people, or will have certain rights (parental, for instance) infringed on.”

    should be

    “I remain unconvinced that fat people will be denied benefits offered to thinner people, or will *not* have certain rights (parental, for instance) infringed on.”


  9. bigliberty Says:

    Agh: “I remain unconvinced that fat people will *not* be denied benefits offered to thinner people, or will *not* have certain rights (parental, for instance) infringed on.”


  10. Bree Says:

    If American UHC were to only focus on wellness and prevention, using those words as codes for weight loss, which the CDC and private insurance companies already do, they’re going to be in for a rude awakening, and a huge loss of money. As Vesta pointed out, WLS ain’t cheap. Putting people on anti-obesity drugs that may have no effect on them also costs money. It’s not going to be profitable for UHC to solely focus on fat as the only health issue to treat, when just being fat for a majority of us does our bodies no ill-will.

  11. Enomis Says:

    Living in Canada with universal health care, I can’t say that I’ve ever been denied care or been told to lose weight before I could get any treatment. On the other hand, I have been denied care for being crazy (repeatedly told I was depressed and doctor-seeking when I was seriously ill with CFS and no one would listen to me).

    Our system was not designed with the idea that some people would be more deserving or less deserving of care, it was built on the mindset that no one who needs it should go without medical care because they can’t afford it.

    Granted, the system isn’t perfect (as my case and loads of others prove). I’m sure there are loads of fatphobic Canadian doctors who tell patients to just lose weight. But I find it really frightening that topics such as who deserves or doesn’t deserve care could even enter into the US debate over UHC.

  12. Lori Says:

    I was thinking more about this, and the big irony, to me, of defining “wellness” as being a certain weight is that many, many medications have weight gain as a side effect. If patients were required to have a certain BMI to be “compliant,” then it would require many of them to not comply with taking medications they were prescribed.

    And, I think doctors are aware of this. The only doctor I’ve ever had raise an eyebrow at my weight noted that I was taking an SSRI and didn’t say a word about my weight after.

    I think, obviously, that assuming a patient is non-compliant if they don’t meet or maintain a certain weight is absurd and wrong, but I see no reason to think that would increase under UHC. Part of the problem now is that people’s insurance plans can make it very difficult to change doctors and really limit who they can see. So, if you do encounter a fatphobic doctor, it can be a huge PITA to change to somebody else. My understanding is that in most countries with UHC people have much more choice about which doctor to go to for routine care. Hopefully any UHC system we implement in the U.S. would make it easier for people to change doctors than it currently is for many people.

  13. amanda Says:

    I’ve often wondered why refusing to treat illnesses or injuries if the patient does not lose weight is not an actionable denial of service. A few years ago, I twisted an ankle while walking to work and, by the end of the day, it had become seriously swollen and painful so I walked the two miles to the emergency room. When I arrived there, the doctor who finally saw me said that my ankle was broken but would not heal because I was overweight, and that I needed to lose weight if he was going to be able to treat it. I thanked him for his time, got up, walked to a drugstore and got splinting materials, walked home, wrapped the ankle and went to work the next day. It hurt quite a bit for several months, and I still have some problems with it, but I don’t regret it.
    On another occasion, I had a really painful attack of arthritis in my knee. I walked up the big hill to the doctor’s office (another doctor) where I was x-rayed and told that I would need a knee replacement but- guess what- couldn’t get one until I lost weight, and that the weight was causing the arthritis. Again, I thanked the doctor, went home, took more aspirin, and eventually the attack subsided and I haven’t had another in the ensuing six years.

  14. bigliberty Says:

    Hi Amanda,

    Did you think of submitting your story to First, Do No Harm? I’m not sure if you’re familiar with it, but it is comprised of stories of fat people who have been mistreated, denied care, mocked, etc by individuals in healhcare due to their weight.

    I’m sorry that happened to you. There is a list of Fat Friendly Health Professionals , so perhaps that could help you find a new doctor that will treat you with respect, regardless of your weight. You deserve it! Doctors don’t treat people differently based on height (and tallness can exacerbate joint injuries just as much as weight can), and weight is just as heritable.

  15. Sandy Says:

    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.

  16. Reply from Sandy to My Last Post « fat fu Says:

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  18. Teleskopik Recordings Says:

    Very interesting and somewhat scary post …

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