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January 31st, 2008

Back in November, Republican presidential candidate Mike Huckabee wrote a remarkably candid essay for a special election issue of the trade journal Modern Healthcare. Since then, the former Arkansas governor’s campaign has morphed from single-digit obscurity to mainstream prominence, and the candor on health care has mostly been scrubbed clean from his Web site. Nonetheless, the essay makes plain Huckabee’s faith in a health care cost containment scheme that sets him far apart from any other candidate in either party. 

His reasoning is straightforward: Three-quarters of disease is chronic. Smoking and obesity cause most chronic disease. I was able to lose weight, and so can you. So when I’m president, the “free market” (incentives? penalties? both?) will ensure that Americans exercise, eat right and stop smoking, thereby savings hundreds of billions of dollars in health care costs. 

More plainly, Huckabee seems to be saying that fixing American health care is as simple as getting smokers to put their butts down and fat people to pick theirs up. 

It is not surprising that Huckabee’s campaign now talks a lot about tax credits and has played down views that risk alienating every voter who’s ever fought a losing battle with the bathroom scale. What is surprising is Huckabee’s more detailed plan has attracted such little attention from competitors or the media. His plan raises not only factual questions, but, perhaps appropriately given his background, even theological ones. (More on that later.) 

First, let’s look at Huckabee’s own words. He writes: “About 75 percent of the $2 trillion we spend annual on health care is spent on chronic disease, most of which could be prevented by not smoking, maintaining healthier diets and exercising. These three lifestyle changes could prevent 40 percent of cancers, 80 percent of type 2 diabetes and 80 percent of heart disease.” Three-quarters of  $2 trillion is $1.5 trillion. “Most” of that means upwards of $750 billion. We’ll come back shortly to his assertions about lifestyle changes. 

Huckabee is the anti-Hillary: personal experience, not a recitation of facts, forms the foundation of his candidacy. His policy prescription is anchored in a personal testimonial, a staple of the evangelical experience: 

In 2003, I was diagnosed with diabetes. As if that wasn’t bad enough, my doctor sat me down and told me that without major lifestyle changes, I was entering my last decade of life. I was only 48! But I was digging my own grave with my knife and fork. I had tried diets before. This time, instead of focusing on losing weight, I focused on achieving true fitness and health. I lost 110 pounds, and this former couch potato is preparing for his fifth marathon. 

Huckabee is certain you can change your life as he did. “Americans who live healthy lifestyles should be rewarded in the cost of their health insurance (just as safe drivers get lower rates on their auto insurance) . . . In a consumer-based system, we have some skin in the game, some incentives to stay healthy . . . so that we’ll have tax-free money coming back to us from our health savings accounts.” He adds, “The reality is that the free market hasn’t been given a chance.” 

The key words here are “skin in the game,” a casual expression connoting side bets on a basketball game or maybe buying a round of drinks after losing a round of golf. (Disclosure: I am a self-employed Democrat who has volunteered for the Obama campaign and am grateful for having any health insurance.) By participating in a high-deductible HSA, consumers are expected to change unhealthy behaviors, avoid the doctor’s office and watch the tax-sheltered money they and their employer have contributed to the medical savings fund grow into a pot of gold at the end of the rainbow. 

Apart from the misplaced confidence in HSAs that Huckabee shares with fellow conservatives – serious and expensive illness is the opposite of discretionary consumer spending – what is conspicuously absent from Huckabee’s narrative is any mention of the “free market” incentives apt to confront adipose Americans. Since two-thirds of men and half of women are now “overweight or obese,” according to a survey by the Centers for Disease Control and Prevention, most Americans have plenty of “skin” to put into this game. The likely way it will play out can be seen from news reports

For instance, at CFI Westgate Resorts in Orlando, a CEO inspired by his own 20-pound weight loss offered attractive incentives to obese employees who lost weight, while saying he would fire any employee who did not quit smoking within one year. (The company offered free assistance in both weight loss and smoking cessation.) In an even closer parallel to Huckabee’s vision, a bank in Geneva, Indiana raised the employee deductible from $500 to $2,500, but offered $500 credits to employees who passed screenings for cholesterol, body mass index, blood pressure and tobacco use. 

Would a President Huckabee replace the Bush administration’s cozy relationship to “fat cats” with hostility to the merely fat? Would a Huckabee government that trims taxes bulk up its revenues by levies on the lazy? Would it discourage food guzzlers rather than gas guzzlers? Clearly, these are not questions any presidential candidate would be eager to address while pressing the flesh, as it were, out on the campaign trail, particularly a candidate who governed what is now ranked as the eighth fattest state in the country. 

To be sure, Huckabee, along with other candidates, deserves credit for highlighting the idea that preserving wellness should be as central to American health care as treating sickness. He is also correct that patients need a financial stake in their care decisions – for example, the percentage of personal health expenditures paid out of pocket plunged from 26 percent in 1985 to 15 percent in 2005, according to a Congressional Budget Office analysis. The problem is that neither Huckabee’s factual assertions nor his implicit assumptions about human behavior bear up to scrutiny. 

Let’s start with the math. A study released in October by the Milken Institute found that treatment for seven chronic diseases (cancers, mental illnesses, heart disease, lung conditions, hypertension, stroke, and diabetes) ran to nearly $280 billion in 2003, the most recent data available. Heart disease treatment carried the largest price tag — $65 billion in direct treatment costs. 

That means that eliminating all those conditions would pay for less than half the savings Huckabee claims for eliminating 40 percent of all cancers and 80 percent of the cost of type 2 diabetes and heart disease. This calculation doesn’t even consider the larger question of whether even reductions of the magnitude Huckabee proposes are realistic. 

If Huckabee’s calculations meant to include the indirect costs exacted by chronic illness, then he might also want to address the $65 billion to $130 billion per year in lost capital and earnings due to poor health and shorter life spans of those with no health insurance, according to figures compiled by the Commonwealth Fund. Exercise and eating right have their limits. While Huckabee denounces those who would impose “universal health care mandated by federal edict or funded through ever-higher taxes,” a recent JAMA study found yet again a direct connection between health insurance (in this case Medicare) and improved health for patients with cardiovascular disease and diabetes, two expensive chronic conditions. 

Perhaps the most glaring omission by Huckabee is any mention of the connection between illness and economic class. It is no coincidence that the states where health status is the poorest are those where the population is the poorest. “Income . . . is among the more powerful predictors of health status,” noted Dr. Steven Woolf, a Virginia Commonwealth University epidemiologist, in a JAMA commentary. “The connections between poverty and disease have been well documented, but even modest reductions in income among more affluent persons can also influence health.” 

Woolf then goes on to highlight the harmful health consequences of increasing poverty rates, decreasing household incomes and widening income inequality. This uncomfortable topic goes unmentioned not only by Huckabee, but by all the Republican candidates, who are too busy heralding the power of the “consumer” to notice what happens when the consumer has no power at all. The evidence suggests strongly that economic disparities explain why Arkansas ranked forty-eighth of fifty states in the number of premature deaths (before age 75) that could have been avoided, avoidable hospital use and similar quality measures. And what about the health impact of tax cuts that starve public schools of revenue and drive them to a market-based trade-off of access to their students’ bodies in return for payments from the companies making sweetened soft drinks and salty snack foods? 

More troubling still is the assumption that our health status is a mirror reflecting our life decisions. In reality, marathon runners get heart attacks. Fitness fanatics contract cancer. Kids who eat their peas and carrots still grow up to develop diabetes. 

To me, however, the most unsettling part of Huckabee’s plan are the moral assumptions that implicitly undergird it. The man or woman most prone to seeking solace in food is not infrequently compensating for emotional nourishment missing in other areas of life. Smokers shivering in the cold to puff on ever-more-expensive cigarettes may as easily be exhibiting signs of addiction as symptoms of moral weakness. As an ordained Baptist minister, Huckabee surely understands that Man is much more than an economic animal. 

Huckabee, who proclaims his acceptance of the Bible as the literal word of God, would do well to reread the Book of Job. Job endures loss of wealth, loss of health and loss of loved ones, only to suffer even more when his friends glibly urge him to search his conscience for what he did wrong to deserve his fate. Instead, Job angrily rejects their smug contention that, in effect, bad things cannot happen to good people. The connection between sin and suffering may become clear in the world to come, but it is not at all obvious in this one. 

“The Book of Job serves to refute . . . a simplistic understanding of the divine retribution principle maintaining that there is an automatic connection between one’s material and physical prosperity and one’s spirituality,” writes Greg W. Parsons, an expert on Job and the professor of biblical studies at the Jacksonville, Tex.-based Baptist Missionary Association Theological Seminary. Man, adds Parson, cannot “pre-determine God’s actions and judge a person’s condition before Him.” 

In other words, while God’s judgment may be the ultimate “skin in the game,” there’s no way we mortals can determine the likely outcome for ourselves or, especially, for others. As a result, religious principles and scientific evidence would seem to agree that a health care policy that relies on the perfectibility of Man’s moral or physical condition is highly unlikely to redeem us from the problems that we face in this life, in this country, today. 

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4 Responses to “HUCKABEE-STYLE HEALTH REFORM: Morally And Physically Fit”

  1. Arvind Cavale Says:

    Being an Endocrinologist who has been caring for thousands of diabetics like Gov. Huckabee, I must agree with his premise and tend to disagree with the authors’ assertions. Collecting economic statistics of what particular diseases cost the “system” is a very inaccurate method of assessment. In fact, I contend that only clinicians can truly explain the real cost to society from chronic diseases and the magnitute of savings that can be achieved by doing exactly what the Governor suggestes in his plan.

    For example, it is amply clear that at least 50% (if not higher) of chronic heart disease is caused as a diabetic complication. In fact, having type 2 diabetes is considered an equal to having had a heart attack! Similar relationships can be made to chronic kidney disease (dialysis), strokes, blindness, etc. Simple economic calculations of what a particular disease costs is a very incomplete method of assessment. It does not calculate the workplace inefficiency caused by chronic diseases, the cost of care-givers (family, nursing aids, etc.) not to mention illnesses that care-givers have due to caring for people with severe chronic illneses. Our daily observations are that those folks who drive up to our office in expensive cars, smoking 2 packs of cigarrettes a day with a Starbucks coffee in their hand are not infrequently those who complain that they cannot afford their medications! I wonder where our society’s priorities lie – may be Mr. Obama has a plan to help such folks. Quite frequently, we sit down with our patients and calculate for them the potential savings just by quitting smoking, that they could possibly use to get their meds. I suppose, that would mean that we’re supporting drug companies’ profits, in the language of the Democrats…

    In my opinion, potential economic savings projected by Mr. Huckabee based on his assumptions may actually be the tip of the proverbial iceberg, the true worth of which may never be able to be quantified in conventional terms as elicited by this author. Why not make it an integral part of a larger strategy? Why shoot a very workable strategy down without even trying?

  2. chaufan Says:

    I also enjoyed Micheal’s post.

    Now I have additional recommendations for Mr. Huckabee:

    Aside from re-reading the Bible to come up with a solution to the health care crisis, it would be useful for him to read a recent commentary in the New England Journal of Medicine (

    It explains in very simple terms why the American health care system (assuming that we have one) is so broken: “it is the price, stupid”, as economist Uwe Reinhardt wrote a few years ago. And we pay such exorbitant prices because of our reliance on private insurers who need a fragmented system to enroll the healthier and dump costly patients on the public sector (i.e. taxpayers), who do NOT need that the purchasing power of “consumers” be put together to regulate them, or, god forbid, get rid of them altogether (such as a single-payer system would do), and who DO need to sell garbage policies (i.e. high deductibles, co-pays and co-insurers) not because of the alleged risk that we will all rush to get a liver transplant if it is offered for “free”, but because they keep their business costs low by figuring out creative ways to not pay for our medical care.

    My second recommendation is that Mr. Huckabee read a recent article in PLOS Medicine, performed by Dutch researchers (

    Their study showed that, while encouraging healthy lifestyles (e.g. telling people to eat their veggies, do their exercise, and not smoke) may be good for people because they will be healthier and feel better, it does not follow that it is a good strategy to control the costs of health care.

    In fact, quite the contrary seems to be true: healthier people tend to live longer, and on the whole, end up by spending more. The “cheapest” patients are smokers, who get lung cancer and do not survive much. And probably the cheapest of all is to let people die. But of course with our current system (and most likely with many of the current reforms) this is precisely what we do: we allow some 18,000 thousand die every year by making it impossible to get perfectly standard medical care (Institute of Medicine, 2003).

    So my two cents: if controlling costs for “the system”, whatever that is, is the goal, we could do so by by making health care so expensive that not even Health Affairs bloggers will afford to see a doctor.

    But if what we want as a people is to make health care affordable so that everybody gets their share, because we want a healthy and happy population that is truly proud to be American, then we might have to deviate from Huckabee’s idiosyncratic “solution” to the health care crisis, stop trying to reinvent the wheel, and look for answers elsewhere.

  3. Brad Kirkman-Liff Says:

    Gov. Huckabee did lose a great deal of weight through a very rigorous program of exercise and managed nutrition. He had written on one website that he had nutritionists at the University of Arkansas develop of personal nutrition program for him. He was able to rearrange his work schedule to do exensive jogging. He was able to reverse his diabetes.

    However, as someone who is obese and has struggled through more than one lifestyle and fitness management program, I have learned that compulsive overeating is not easy to defeat. He was able to, but many other people try and fail – repeatedly. There may be profound emotional and in some ways spiritual aspects related to an addictive disorder like compulsive overeating. It is important that we do not further complicate a problem such as obesity
    by proposing a simple solutions like economic incentives and social stigmatization. More effective disease management programs, better use of social networking technologies for social support, more effective medications that suppress appetite or moderate fat metabolism, and more insurance coveragfe for bariatric surgery might be more effective in the long run.

  4. mgoozner Says:

    Hi Michael,
    I really enjoyed this post, but I wanted to quibble with just one of the “facts” you use to support the idea that consumers should have more skin in the game. It is true that the individual share of health care spending has declined over the past 20 years, as the CBO reports. But that’s masks the fact that individuals and families have also seen their out-of-pocket costs rise in relationship to income. Do you know anyone paying lower co-pays and deductibles? Overall health care spending over much of that period rose at two to three times economic growth. Business and government picked up most of that tab, and thus increased their share. But individual costs rose, too, even as their share declined.

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