Overselling Breastfeeding

October 21st, 2015 No comments »

Courtney Jung has an interesting opinion piece in the New York Times, “Overselling Breastfeeding.” The writer points out that the goals for the duration of breastfeeding are more accessible to upper and middle-class white women than other mothers. Furthermore, she decries the drift from making breastfeeding a choice for mothers to make to policy decisions which penalize non-breastfeeding mothers. She writes, “Demographic differences in breastfeeding rates also justify government interventions that punish poor women who do not breastfeed. This isn’t just the little unobtrusive little “nudge” in the right direction, designed to compel people to make better decisions. It’s more like a shove, with a kick for good measure.”

Jung notes that arguments that breastfeeding prevents childhood obesity have been largely disproved. See our analysis on this point.


EEOC punts on Employer Wellness Regulation

April 17th, 2015 No comments »

The Equal Employment Opportunity Commission (EEOC) has finally issued proposed amendments to the Americans with Disability Act (ADA) regarding employer wellness programs.

The proposed regulations are very disappointing. They re-define “voluntary” participation in a wellness program to mean being penalized 1/3 of an employee’s health insurance premium cost. The average cost of single coverage is $5,615, with employees paying $951 out of pocket. More and more of the cost is being shifted to employees. Many employees, especially white women, suffer a wage penalty because of their weight. And most employees’ health insurance plans do not cover the costs of FDA approved medicines for weight loss, bariatric surgery or intensive behavioral interventions.

In particular, the proposed regulations do not require employers to tell employees of the availability of alternative avenues to receive the reward or avoid the penalty. They do not require employers to leave the final word on alternative avenues with the employee’s physician, which is required in the DOL/HHS regulations. There is no obvious penalty if the employee’s personal health data is not adequately protected by the employer and personal health data is used to an employee’s detriment. On the other hand, one useful provision limits the penalty/reward to 30% of the premium cost of a single person. Obviously, this is lower than the cost of family coverage. Industry is sure to fight this limitation, as they want to increase the size of the penalty/reward.

Comments are open until June 19,2015.

See EEOC press release here. See proposed regulations here. For additional information, see Ted Kyle’s blog here, and Tim Jost’s blog in Health Affairs here.

In the meantime, the federal government’s Office of Personnel Management (OPM) has told federal agencies to promote workplace wellness programs.


Opportunity to Expand Coverage of Bariatric Surgery and Anti-obesity Drugs

January 6th, 2015 No comments »

Kaiser Health News reports today on the poor coverage of drugs for obesity by Medicare and private insurance plans. Health plans which are part of the health exchanges established by the Affordable Care Act also have poor coverage. However, there is a strategy to deal with the health exchange ( or marketplace) plans.

As reported here in a paper (see p.8)  Christopher Still and I wrote on the Affordable Care Act’s impact on persons with obesity, the law has a unique provision allowing for review of plans for ‘discriminatory benefit design.’ Robert Pear of the New York Times reports that the Center for Medicare and Medicaid Services is looking at plans to see if their benefit are structured to discriminate against persons with H.I.V./AIDs, autism, diabetes, bipolar, schizophrenia and other diseases. The article reports that the Obama Administration has said it would challenge restrictions on benefits if they were “not based on clinically indicated, reasonable medical management practices.”

This is a huge opportunity for the obesity community to persuade CMS to look at the lack of coverage of anti-obesity drugs and bariatric surgery in plans on the health marketplaces. It is also an opportunity to have CMS look at whether health plans are adequately including behavioral counseling for adult obesity as they are required to do.


Update on State Medicaid Expansion Under Obamacare

February 8th, 2014 No comments »

State ReforUM tracks state-level health care reforms. Check out their updated map of what states are doing in expanding Medicaid, pursuant to the Affordable Care Act (ACA). See the story on what South Carolina is up to.


The Affordable Care Act’s Impact on Persons with Obesity: The Full Report

October 4th, 2013 No comments »

The Affordable Care Act’s major impact on persons with obesity is historic. Assuming that 34% of the 170 million adults with employer-based health insurance are obese,  57.8 million adults with obesity will be protected from losing coverage due to pre-existing conditions, have no annual or lifetime caps, a right to external, independent review of denied claims, rights in employer wellness programs and a new benefit, intensive behavioral counseling for obesity. An estimated five million persons with a BMI >30 may enroll in Medicaid and be eligible for intensive behavioral counseling for obesity, if all those eligible enrolled. The same is true for an estimated 3.8 million American adults under the age of 65 with obesity eligible to enroll in the state exchanges. In state exchanges, a strong non-discrimination provision based on “benefit-design” appears to provide the legal foundation to expand coverage of drugs for the treatment of obesity and bariatric surgery. In short, an estimated 66.6 million Americans with obesity will have new protections, rights and benefits on January 1, 2014.

See details on changes in current private insurance plans, Medicaid, state exchanges, prevention, research and restructuring of the health care system.

Christopher Still and I have written up the full details in this new 15 page report: The Affordable Care Act.

Obamacare Premiums Lower Than Expected

September 25th, 2013 No comments »

The Department of Health and Human Services has released data on the premiums for health plans in the state marketplaces/exchanges which come online in two weeks. The plans go into effect January 1, 2014. Premiums nationwide are around 16% lower than expected. About 95% of eligible uninsured live in states with lower than expected premiums. Click here for the full report.


Obesity and Obamacare: A Practical Guide

September 15th, 2013 No comments »


By our estimates, some 65 million Americans with obesity will be impacted by Obamacare. Many provisions of the Affordable Care Act, known as ‘Obamacare’are already in place. But October 1, 2013 will be a milestone as millions of uninsured Americans can start enrolling in health marketplaces (formerly called ‘exchanges”) for coverage starting next year. The law is complex and it’s no wonder most Americans don’t understand it. We’ve tried here to distill the basic information for consumers, especially those with obesity, who had problems getting or keeping insurance or getting reimbursement for obesity treatments.

Here’s where Obamacare will make a major impact:

56 Million Americans with group or individual insurance now have new security against exclusions for pre-existing conditions, rescissions of their contracts, rights to independent review of denied claims and new protections for employer wellness program abuses. They will also be eligible for intensive counseling for adult obesity.

5 Million Americans with obesity would come into the Medicaid program under Obamacare if all the states adopted it.

3.7 Million Americans with obesity are likely to enroll in health marketplace (exchanges) where they will be entitled to intensive behavioral counseling of obesity, and at least one prescription drug for obesity treatment.2

Here some FAQs to help navigate Obamacare:

Q. Does Obamacare affect me?

A.  Effective January 1, 1014, everyone must have health insurance or else be subject to a tax. For specific information, see this IRS page.

Q. Are there exemptions?

A. Yes. See the IRS page above. In addition, if you live in a state which has not elected to expand their Medicaid program you will be exempted from the individual mandate. Federal regulations treat this situation as a ‘hardship exemption from the individual mandate.


Q. Does Obamacare change Medicare?

No. No one on Medicare needs to buy anything or answer any questions from callers. Because of the confusion around the law, scammers are calling folks asking for personal financial information on the basis that they are asking if they are qualifying for health insurance. Don’t believe them.

If you have Medicare the only change Obamacare makes is to shrink the prescription drug ‘donut hole.’ Supplemental insurance programs will not change.

Group or Individual Plans

Q. I have health insurance at work through a group plan. I’ve been told there will be no changes. Is that right?

A. Not really.  In the private insurance market, both group and individual plans, exclusions for pre-existing conditions will be banned, as will annual and lifetime caps on reimbursement.  All private insurance plans starting in 2014 must cover intensive behavioral counseling for obesity in adults. (That’s about 56 million people with obesity.) There are new rules giving you the right to appeal denials of claims to independent outside reviews. New rules on employer wellness plans gives employees rights to alternative avenues to benefits and puts your individual physician in charge of what is right for you. Other changes, as with the tax deduction for medical expenses and a future ‘Cadillac’ tax on expensive health plans are less positive for affected persons.

Q. I have health insurance at work through a group plan and we have been told the rates we pay for it will go through the roof because of Obamacare. Is that true?

A.  Health insurance premiums are going to vary by age, your state and what kind of plan you purchase and whether you qualify for federal subsidies. And they will vary by what strategies your firm takes. For example, some employers are moving full time workers to part time status; others are reducing family or dependent coverage. Recently, premiums have been fairly flat. A RAND study predicts small firms with under 100 employees will see a 6% reduction in 2016 health insurance premiums.

The Kaiser Family Foundation published a study of premium changes in 17 states and the District of Columbia, with and without the tax subsidies. Check it out here.

Q. What about rates if you buy individual health insurance?

A. A RAND study found little likelihood of big increases in premiums in the individual market but there are government subsidies for almost half the polulation. Forbes has published this map and information on what they project.  The Forbes’s site also has a calculator to see if you might be eligible for federal subsidy. Kaiser Health News has estimated that about 48% of adults already purchasing coverage for themselves will be eligible for subsidies next year and those subsidies will average $5,548 per family.

Kaiser Health News has provided detailed information on how the subsidies will work.


Q. I’m uninsured because it costs too much. What does Obamacare do to help?

A. If you make 133% of the federal poverty level or less,  you may qualify for Medicaid. If your income is 4 times the federal poverty level or less, you qualify for federal subsidies to make purchasing a private plan affordable. When you apply on a health marketplace (exchange) the system will automatically determine if you qualify for Medicaid in your state.

Q. My state won’t expand Medicaid so I won’t be eligible? Can I still get insurance through ObamaCare?

A. There seems to be a way but it’s a little tricky.

Q. When can I enroll in ObamaCare?

We’ll assume by ‘Obamacare’ you mean the state health marketplaces. You can start the paperwork now. October 1, 2013 the open enrollment starts. Sign up here.

Q. Am I eligible?

A. Nearly everyone is eligible. Go to this site.

Q. I need health insurance but don’t make much money. I am very healthy and active. Can’t I just wait until I’m sick and then get insurance from a health exchange?

A. That’s a risk. You can only enroll during open enrollment periods. If you need health insurance after one period closes, you will have to wait until the next open enrollment period to enroll. Any costs you incur then will be your responsibility. In addition, there is a (modest) tax for not having health insurance.

Q. What kind of health plans will be available?

A. There will four types of plans: bronze, silver, gold and platinum. Basically, with bronze, the premiums will be the least expensive but your out-of-pocket costs will be the highest. With platinum, it’s reversed: they will be the most expensive but your out-of-pocket costs are the lowest. They all have to provide “essential health benefits” but who provides and where will vary. More information is available here.

Q. What will be the premiums in the health marketplaces (exchanges)?

A. The Kaiser Family Foundation published a study of premium changes in 17 states and the District of Columbia, with and without the tax subsidies. Check it out here.  A similar analysis is available from Avalere Health here.

This site compares premiums inside and outside the marketplaces (exchanges),

Q. What are ‘essential health benefits’?

A. ‘Essential Health Benefits’ are specific types of health care services. Preventive services are one of the ten types and include intensive behavioral counseling for adult obesity. Plans will also have to have at least one drug from every therapeutic category. So one of the current FDA approved drugs for obesity should be available. Bariatric surgery may vary. However, the law contains very strong language that plans cannot discriminate in “benefit design” Read the federal regulations. This language should provide the legal justification for coverage of bariatric surgery.

Q. I’m still confused. Is there anyone in my state to help me?

A. For information on consumer assistance, see Families USA http://www.familiesusa.org/resources/resources-for-consumers/consumer-assistance-programs-resource-center/;

A State-by-State Map of consumer assistance resources is also available.

Q. I have family member who is not just obese but has some mental and other physical problems as well. She finds it hard to find services in her area and needs care across her problems. Any help?

A. One change to Medicaid in the ACA may be especially useful to persons in her situation. It creates an optional Medicaid benefit (Social Security Act §1945) for states to establish “Health Homes” to coordinate care for people with Medicaid who have chronic conditions. Health Homes are for people on Medicaid who have 2 or more chronic conditions, have one chronic condition and are at risk for a second, have one serious and persistent mental health condition. Chronic conditions include mental health, substance abuse, asthma, diabetes, heart disease and being overweight (BMI >25). Health Homes are intended to integrate and coordinate all primary, acute, behavioral health and long-term services in support of the whole person. More.

There is more information on these two government sites Healthcare.gov and CMS.


1. Decker, SL, Kostova D, Kenney GM, Long SK, Health Status, Risk Factors, and Medical Conditions Among Persons Enrolled in Medicaid vs Uninsured Low-Income Adults Potentially Eligible for Medicaid under the Affordable Care Act. JAMA, 2013; 309(24):2579-2586. http://www.ncbi.nlm.nih.gov/pubmed/23793267, accessed Sept. 13, 2013.

2. The Urban Institute, Health Status of Exchange Enrolees: Putting Rate Shock in Perspective http://www.urban.org/UploadedPDF/412859-Health-Status-of-Exchange-Enrollees-Putting-Rate-Shock-in-Perspective.pdf




ObamaCare Starts Now

August 22nd, 2013 No comments »

While the ‘exchanges’ will not be operational until October 1, individuals in 34 can now start the enrollment process by going to this site.