Get-off-your-butt money!

As the era of “sit-down money” for Aborigines ends, the Australian General Practice Network has proposed a new scheme to give “sit-up money” to the obese.

The AGPN wants over-weight patients referred by their doctor to an accredited weight-loss program to receive a $170 government-subsidy to cover 75 per cent of the cost.

The federal government and opposition have agreed to consider the proposal.

Little wonder. According to Melbourne University Associate Professor David Dunt, the cost of treating obesity-related chronic conditions, such as Type-2 diabetes, accounts for nearly 70 per cent of allocated Commonwealth health expenditure. When diabetes leads to end-stage kidney disease, patients require renal dialysis. In 2005-06, public hospitals admitted more patients for renal dialysis than for any other reason.

Because so many unhealthy Australians are requiring costly, complex, and recurring treatments, investing in preventative measures to address the obesity crisis seems like a good idea.

But can and should Medicare be paying for this?

Taxpayer-funded health systems like Medicare were designed to deliver relatively cheap and basic care to people who contracted an infectious disease, or who were injured in an accident. The idea was to share the risk of misfortune equitably between the rich and poor, and ensure the cost of ill health did not ruin the less wealthy.

But thanks to modern medicine, Medicare is increasingly saving people from themselves. Once, if you ate poorly all your life, you died of a heart attack in your 50s or early-60s. Now you can escape the consequences of your lifestyle because open-heart surgeons can unclog your arteries.

This means that today there is less reason than ever before to take care of your health, regardless of the enormous social cost, particularly when healthcare is largely “free”. While ever Medicare foots the bill and protects people from the consequences, this will not encourage people to modify their lifestyle.

However, social policy experts recognise that unless there are consequences, people will not change their behavior. They also recognise that the best way to promote positive social outcomes is to link entitlement to social welfare to good behavior. Hence, people are no longer paid unemployment benefits unless they fulfill mutual obligations and actively look for work or agree to work for the dole.

The same idea of encouraging personal responsibility is behind the federal government’s intervention in Northern Territory aboriginal settlements. Fifty per cent of welfare payments have been quarantined because the free flow of “sit down money” led to socially destructive behaviour - primarily alcohol abuse - in these communities.

But there is a reluctance to extend this approach to health. This is largely because we continue to think about healthcare in terms of protecting people from misfortune, even though Medicare clearly no longer functions this way.

While unhealthy lifestyle is recognised as the major cause of chronic illness, what is not acknowledged is that Medicare encourages, subsidises, and rewards this behaviour by allowing the unhealthy to consume the bulk of the community’s health resources.

The AGPN’s solution to the obesity crisis is to continue down this path, and increase the reward for being unhealthy by creating yet another subsidy. And to what end? To “educate” people about what they surely must already know: that a poor diet and no exercise makes you obese.

But the incentives in the health system are set to change. As the population ages in coming decades, increasing numbers of elderly people in particular are going to suffer chronic illnesses. In some parts of Britain, health authorities have already moved to cut costs by denying expensive hip replacement surgery to obese people.

As the rising cost of treating “lifestyle” disease places an unsustainable strain on Medicare, similar bans are inevitable in Australia. Medicare simply will not be able to provide all possible therapies and procedures to all patients on demand. Lifestyle is set to become the key criteria used to refuse certain treatment to certain patients.

Rather than sit-up money, increasing the public’s awareness of the realities of healthcare in the 21st century, and what the consequences of a poor lifestyle will be, is a more effective way of tackling the obesity crisis. This should give people a real incentive to lose weight.