Gut Check

What's missing in the marketplace

By Ezra Klein
Wednesday, October 28, 2009

Ezekiel Emanuel -- older brother to not only Rahm but also Hollywood superagent Ari -- is sometimes called the nicest Emanuel brother. And he certainly seems it as he browses through artisanal jam on a warm Thursday afternoon in October.

Think Rahm eats artisanal jam?

Ezekiel Emanuel doesn't get a lot of time for shopping, though. He spends his days, and a good chunk of his nights, holed up in the Eisenhower Executive Office Building, where he serves as health-care policy adviser to Office of Management and Budget Director Peter Orszag, applying his long experience as an oncologist and bioethicist to health-care reform. Today, however, he's showing me around the White House farmers market, which he helped start in the few moments he's had to stop worrying about health care and start worrying about, well, health.

The White House farmers market is not, in fact, operated by the White House. It's a project of FreshFarm Markets, and it looks a lot like other markets you've been to: stalls, produce, bread, some goods that look like craft projects from a small liberal arts university. But it was started with White House involvement, and it illustrates an interesting point. A couple of miles away, Congress is contemplating the most ambitious transformation of our health-care financing structure and delivery system that has ever been attempted. But when it comes to visible symbols of the government's engagement with one of the primary inputs into our health -- what we eat -- all we have is a farmers market that was started with White House involvement.

Perhaps I'm being unfair. There was money for prevention and wellness programs in the economic stimulus program enacted in February. There are myriad programs -- some good, some bad -- at the Department of Agriculture. Michelle Obama and her staff have been aggressively engaged with food policy. And there is, of course, the much-publicized White House vegetable garden. But the issue here is not so much the level of engagement as it is the points of entry. The government really doesn't know what its role should be when it comes to how Americans eat. It knows that it can't afford Medicare and Medicaid if the rise in such diet-related conditions as diabetes, heart disease and cancer doesn't level off. But what does that imply? Should Peter Orszag publish a cookbook? Should Emanuel have a cooking show? Should fruits and vegetables be heavily subsidized? Soda taxed? The head of Hardee's executed?

Our political system is a lot more comfortable talking about health care than about health. We'll pay enormous amounts of money to treat diabetics, but we don't do much to change people's diets to prevent diabetes. That's a strange use of resources: Focusing on health-care coverage without doing more to address the factors, such as diet, that determine our health is a bit like buying fire insurance while ignoring the fact that you have a gas stove and a large fireplace in a wood cabin. A dry wood cabin.

It's better to prevent fires than rely on fire insurance, as homeowners know. But preventing fires, it turns out, is really hard. "My own view," says Emanuel, "is we know there are large parts of health that are primarily best approached as a public-health issue and not as a doctor-patient issue. Nutrition, wellness, exercise and smoking, for instance. But lifestyle change is hard to accomplish. What smoking showed is it's not a single thing. It changed from being socially acceptable and doctors would recommend it in the '50s to being scorned and barred indoors."

The smoking case is an interesting one. Emanuel brings it up repeatedly as one of the few examples where public-health advocates managed to change the culture around a previously unexamined act, which is exactly what they're going to have to do with diet. "On smoking, there are a combination of things that had to happen," he says. "We had to make smoking socially unacceptable. We took it outside the building. We raised taxes on it. It became linked to cancer." But as he admits, "you can't take eating outside the building." Nor can you demonize it entirely. Certain products can be attacked, but in a world of organic Oreos and Splenda with added fiber, it won't just be an uphill climb. It'll be a climb with constantly changing footholds.

Moreover, as Emanuel says, lifestyle issues are hard for the government to address. They're personal, for one thing. Whether it likes it or not, the government is fiscally invested in the way we eat because it pays for the consequences of a bad diet. But few feel comfortable with the government's involving itself in the choices that lead to that bad diet.

Even if the discomfort could be surmounted, there aren't that many levers the government can use. If doctors want to keep getting checks from Medicare, for instance, they have to take its recommendations seriously. But even including federal subsidies for agriculture, the government isn't particularly involved in our dining decisions, and it doesn't want to be.

So where does that leave us? "You have to change the whole culture around this stuff," Emanuel sighs. "That's a complicated thing. It's even more complicated than how to change the health-care system, if you can believe it."

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