Posts Tagged ‘Affordable Care Act’

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

January 6th, 2015

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.


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

October 4th, 2013

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

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


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;

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 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., accessed Sept. 13, 2013.

2. The Urban Institute, Health Status of Exchange Enrolees: Putting Rate Shock in Perspective




ObamaCare Starts Now

August 22nd, 2013

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


Obesity and Essential Health Benefits: The Final Rule

February 21st, 2013

The Department of Health and Human Services issued final regulations defining “Essential Health Benefits” which will have to be included in insurance programs listed on state exchanges and all non-grandfathered health insurance plans in the group and individual markets. The EHB covers 10 categories covering hospitalization, prescription drugs, etc. See Fact Sheet.

The regulation is generally close to the proposed regulation with the exception of expansion of mental health, habilitative care and pediatric dental and vision services.

Last July, interim final regulations were issued which require these plans to include under prevention and wellness, the US Preventive Services Task Force recommendations, which include Intensive Behavioral Counseling for Adult Obesity.

Unfortunately, it appears that HHS has no problem with allowing most state exchanges to use “benchmark” plans which exclude bariatric surgery, according to a report by the Obesity Care Continuum. Coverage of prescription medicines for obesity is murky. The EHB regulations state that plans must provide at least one drug in each category or class of the US Pharmacopeia. But it uses version 5.0 for Medicare. Under the Medicare statute, Part D, drugs to treat obesity are excluded so they don’t appear to be covered. However, this might be challenged under the EHB rules that the benefits must be designed in a manner which does discriminate based on age, disability, or expected length of life and must take in the needs of a diverse population.

The regulations limit deductibles to $2,000 for individual coverage and $4,000 for family coverage.

The STOP Obesity Alliance and my own comments, had argued for more clarity in the inclusion of obesity treatments.


US Chamber of Commerce Decries “Coddling” of Employees In Wellness Regs

February 7th, 2013

There were three particularly noteworthy comments on the proposed regulations on employer wellness plans.

The U.S. Chamber of Commerce challenged the proposed regulations statement, “A health-contingent wellness program is not “reasonably designed” unless it makes available to all individuals (who do not meet the standards based on the measurement, test, or screening) a different reasonable means of qualifying for the reward.” The Chamber says that this is contrary to the Affordable Care Act provisions. They state, “Wellness programs should not be required to coddle apathetic participants as the Proposed Rule’s pursuit of an “everybody wins” approach will thwart the very motivation that a rewards based program is designed to create.” The Chamber urged that the penalties be raised to 50% for all programs, not just smoking cessation. They also called for “stacking” whereby the penalties would be additive: 50% for not meeting the smoking standard plus 30% for not meeting the other health-contingent plan biometrics or up to 80% of the cost of the worker’s health insurance premium.

Other comments were less harsh. Gloria Sorensen and Deborah McLellan of the Harvard School of Public Health, Center for Work, Health and Well-being, wrote that the wellness programs need to encompass the worksite itself, “Risk factors for cardiovascular disease that may occur at work include exposure to chemicals in tobacco smoke; organizational factors such as work schedules (e.g., long hours and shift work); and psychosocial factors such as high demand-low control work, high efforts on the job combined with low rewards, and organizational injustice,” they wrote.

They note, “Additionally, many traditional wellness efforts have had low participation rates by populations at highest risk for unhealthy eating, smoking, and physical inactivity… such as those in working-class occupations. Such workers may lack the time and energy to engage in these programs, either because the programs are often held during the day when workers cannot attend, or after work when employees many need to leave for another job or family responsibilities. Notably, these populations are also frequently at high risk for exposures to workplace hazards.”

Ted Kyle, writing for the Obesity Society, the Obesity Action Coalition, the American Society for Metabolic and Bariatric Surgery, the Yale Rudd Center for Food Policy and Obesity, the American Institute for Cancer Research, the Academy of Nutrition and Dietetics and Mental Health America, notes that, “there is little evidence supporting the effectiveness of employer BMI and other biometric-based incentives on actually producing sustainable weight loss or lowering healthcare costs…There are many individuals who are not overweight e.g., with a BMI in the ‘normal weight range) who have chronic health conditions such as hypertension, hyperlipidemia, diabetes, or engage in other health risk behaviors. Conversely, there are people who are overweight who are in good health, have healthy nutrition and activity habits, and whose blood pressure and cholesterol are in the healthy range.” The Kyle letter rightly points out that these programs penalize  pre-existing conditions.” The letter recommends employers not use BMI or body size only metrics without consideration of additional health indices and that the employers insurance programs cover evidence-based obesity treatments.

All comments on the proposed regulations can be viewed at


Employer Wellness Incentives Questionable Origin

January 30th, 2013

The provision of the Affordable Care Act expanding the amount of the incentive/penalty in mandated health-contingent wellness plans was put forward by Senate Republicans at the urging of Safeway CEO Steve Burd during the 2009 debate over health care reform. Burd launched a whirlwind lobbying campaign claiming great improvements in employee health and lower costs for the company. President Obama embraced the proposal. The Safeway plan, called Healthy Measures, gives employees reduction in their insurance premiums if they are, and stay, within certain limits on four medical risk factors: smoking, obesity, blood pressure and cholesterol. Rebates for achieving the goals total nearly $800 for an employee or $1,600 for a family. People who test within the limits get lower health premiums at the outset of the year. An employee who fails the obesity test can get a retroactive payment if he or she loses 10% of his or her body weight by the end of the year. But if the person’s BMI is still over 30 at the beginning of the following year, the payment is withheld until the employee reaches the permanent goal of under a BMI of 30. (See, Bensinger Gail, Corporate Wellness, Safeway style,  accessed Jan. 29, 2013)

The lobbying campaign has been controversial. In a story titled,Misleading Claims About Safeway Wellness Incentives Shape health-care Bill,” David S. Hilzenrath of the Washington Post, wrote,

It’s a seductively simple solution to rising health care costs. Require workers to pay higher premiums if they flunk tests for measures such as weight, blood pressure and cholesterol. Then, bingo: You not only get a fitter workforce, you slash medical expenses.

Politicians of both parties have embraced that idea and expanded upon in the Senate reform bil, inspired largely by the claims of Steven A. Burd, Safeway’s chief executive. Burd says he as set an example for employers nationwide by rewarding employees for healthy behavior. “Safeway designed just such a plan in 2005 and has made continuous improvements each year,” Burd wrote in the Wall Street Journal. “The results have been remarkable,” he declared, adding that “our health care costs for four years have been constant.”

If only that were true.

In a legislative debate filled with misconceptions, few rival the myth about Safeway, which has become the poster company for a provision that big employers and insurers covet. The supermarket chain’s story show how the untested claims of interest groups can take on a life of their own and shape national policy.

As the House and Senate work to meld their bills, the Senate’s “Safeway Amendment,” which would more than double the potential rewards and penalties tied to wellness tests, has become a point of contention. Business groups have pushed for the increase, arguing that financial incentives encourage workers to take responsibility for their health. Opponents such as the American Heart Association and the American Cancer Society say the provision would undo a central element of reform – the promise that people’s premiums would no longer be influenced by their health status.

Rewarding or penalizing people based on wellness tests may save money over the long run, but Safeway hasn’t proved it. In the meantime, based on 2009 data, if the Safeway Amendment becomes law, American families with average health benefits could have $6,688 a year riding on blood tests and weigh-ins.

But a review of Safeway documents and interviews with company officials show that the company did not keep health-care cost flat for four years. The costs did drop in 2006 – by 12.5 percent. That was when the company overhauled its benefits, according to Safeway Senior Vice President Ken Shachmut. The decline did not have anything to do with tying employees to test results. That element of Safeway’s benefits plan was not implemented until 2009, Shachmut said.

After the 2006 drop, costs resumed their climb, he said…

Today costs are slightly higher than in 2005, Shachmut said.

So, when Safeway said it had flatlined costs since 2005, “we defined that, you might say, loosely,” he said. “Perhaps a more precise way to say it is that our costs today on a per capita basis are essentially the same as they were in 2005.”…

Burd’s assertions about the program’s success made him a rock star on Capitol Hill. He pressed his case in briefings for Senate Democrats and Republicans and in a May meeting with President Obama. Leading policymakers have cited Safeway as a model…

Obama has repeatedly invoked Safeway’s approach. “It’s a program that has helped Safeway cut health-care spending by 13% and workers save over 20% on their premiums,” he said in a June speech to the American Medical Association. “And we are open to doing more to help employers adopt and expand programs like this one.”

When Obama delivered those remarks, the program was less than six months old, and by Safeway’s own analysis the spending in question was on the upswing…

Safeway’s expanded incentives are rooted in a philosophy. “I have no problem with a smoker having a 10-pack-a-day habit an killing him or herself,” Shachmut said. “I mean, it’s a personal choice. It’s a free country. I just don’t want to have to pay the health-care costs of that personal choice.” (Editor’s note: This philosophy might be better grounded if the employer did not set the wages of the individual who is obese or smokes lower than peers in anticipation of extra health care costs. See these comments.)

In accessing the economic impact of incentives, it might be helpful to know who health-care expenses for employees in the voluntary Healthy Measures program with those for the rest of the Safeway workforce. Shachmut declined to provide such information. “We frankly haven’t been disclosing that,” he said. “And I would just prefer not to.” Pressed further, he said the data would not be available until April (2010) or later – long after Congress and the president aim to enact a health-care bill.” Hilzenrath D. Misleading Claims About Safeway Wellness Incentives Shape health-care Bill,” David S. Hilzenrath Washington Post, January  17,2010, accessed Jan. 30, 2013. (Hilzenrath is now editor in chief of the Project on Government Oversight,