MY MOM MUST resent what my older sister and I did to her figure. Until we came along, she had a smoking body—I’ve seen the pictures. Long shapely legs, tiny waist, buns the shape of two perfect French batards. But 18 months of pregnancy left my mom carrying an extra 20 or so pounds; 18 years of grabbing meals on the go as she ferried us from school to piano lessons and volleyball tournaments turned that 20 into, well, a lot more. Today, my 59-year-old mother is part of the 66 percent of American adults who are considered overweight.

Which is part of why I find myself struggling with this quandary: Should obese individuals pay more for health insurance? After all, obesity-related illnesses like heart disease, high blood pressure, diabetes and high cholesterol cost Americans more than $75 billion in 2004; the obese also accrue average lifetime medical costs $10,000 higher than those of non-obese folks, according to a 2004 report by researchers at Stanford University and the RAND Corporation, a California think tank. It’s a question the Oregon Health Fund Board, which was established by the state legislature in 2007, should have the guts to consider—as some private companies already have—when it makes recommendations for reforming Oregon’s health care system to stem rising costs in October. Because if we weren’t so jiggly in the middle, we might not pay so much for our insurance in the first place.

“A large part of rising health care costs is related to chronic disease,” says Susan Pisano, vice president of communications for America’s Health Insurance Plans, “and many of our major chronic diseases are related to obesity.”

The problem is particularly prevalent in Oregon, where nearly 25 percent of the population is obese—a figure that officially makes us the fattest of the West Coast states. According to the Center for Disease Control, a person is “obese” when they hit a Body Mass Index (or BMI) of more than 30, a number that corresponds to a basic calculation of weight and height. (For example, someone who is 5 feet 4 inches and 175 pounds just sneaks into the CDC’s obese category.) To accommodate our burgeoning girths, Portland now has hospital beds and ambulances specially designed for plus-size people. You can even supersize your coffin upon passing. So widespread is the problem that last year’s Oregon legislature declared obesity a state emergency, and established a separate task force to develop a plan for reducing obesity and its attendant diseases.

Our weight problem is eating away at our wallets, too: Obesity-related diseases cost the state an estimated $781 million in 2003. Those costs get passed on to insurance companies, then to employers and eventually to employees. In some places, the private sector is looking to trim the fat from the system on its own. Last summer, the Indianapolis-based hospital system Clarian Health announced plans to charge obese employees up to $60 more per month if they didn’t meet certain wellness goals by 2009, like a BMI of less than 30 (though the company reverted to a voluntary wellness plan amid cries of “fattist” discrimination).

This isn’t the first time employers have scrutinized employees’ lifestyles outside the office: In the ’20s, Henry Ford’s employees faced dismissal if they didn’t conform to company ideals about alcohol and nicotine consumption, something his “Sociological Department” monitored with home visits.
“It’s a slippery slope when you get into the idea of social policy,” says Mike Bonetto, a member of the Federal Laws Subcommittee of the Oregon Health Fund Board. “People are sensitive when you start talking about charging more for health conditions.”

But increasing premiums for the obese does not mean a return to a Henry Ford-style regime; it would simply mean acknowledging the double standard that exists in the present health care system: Smokers, for example, have been paying higher premiums for their vice for years. And some individuals, as a matter of routine, are summarily denied health insurance coverage for any number of things, from arthritis to old sports injuries to abnormal heartbeats. Even those who are insured through employers’ group plans aren’t necessarily covered for “preexisting conditions”—including those over which they have no control, such as asthma or even cancer. So why not obesity? After all, it’s on the verge of replacing smoking as the leading cause of preventable death, according to the National Center for Chronic Disease Prevention and Health Promotion.

Coming to terms with what is essentially a fat tax isn’t easy. It requires a shift in how one thinks about health insurance. While I personally believe in basic coverage for everyone—fat, feeble or otherwise—that’s not the reality of our health care system. Many insurers are for-profit businesses that are about risk and the bottom line—in America, health insurance is a privilege, not a guarantee.

Actually, it’s not all that different from auto insurance, a system in which we accept all kinds of discrimination: If you’re a man, you may pay more. If you choose to buy a souped-up sports car, you will pay more. If you rack up speeding tickets, your rates will ratchet up as well. Choosing risky lifestyle behaviors—be it sucking up cigarettes or supersized meals—is basically the health insurance equivalent. The difference is that in auto insurance, you might also get a safe driver discount if you don’t have any accidents. So where’s my skinny discount?

Turns out, some places already have one. Starting in 2006, county employees in Benton County, Arkansas, were able to reduce their deductible from $2,500 to $500 by keeping a low BMI and taking yearly physicals. And Regence BlueCross BlueShield of Oregon, the state’s largest health insurer, began offering a new plan in October, Vitality, that encourages employees to keep fit by rewarding those who work out and eat healthy with gift certificates to places like Borders and Target. These incentivized health programs seem to be successful at reducing health care costs: A Journal of Occupational and Environmental Medicine study reports that one company with an incentive program, GlaxoSmithKline, saved roughly $5.5 million dollars in health care costs over a four-year period.

Practically, these kinds of wellness programs are the same thing as a fat tax; they’re just more diplomatic. But maybe a semantic shift is all that’s really necessary to make the bitter pill go down. I pitched the theory to my mom, hoping she wouldn’t disown me.

“If you told me I had to pay more for my health insurance because I’m overweight, yeah, I’d be angry, even though being heavy is largely my choice,” she said. “But when you put it like that, it somehow seems better. I suppose it’s all just a matter of perception.”

“So,” I pressed in an e-mail, “you won’t write me out of the will for suggesting this?”

“No,” she responded. “We’ll just use your inheritance to pay our premiums.”