The current health care reform debate has crucial implications for the prevention and treatment of obesity. This debate will be followed closely in the months, if not years, ahead. Here is my view of some of the critical issues in the current debate. MD

October 16, 2009

Senate Finance wellness loophole undercuts reform goals.  Wellness Incentives Could Create Health-Care Loophole – washingtonpost.com

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Has America Reached its Tipping Point on Obesity?

The two most recent surgeons general, Dr. David Satcher, left, and Richard H. Carmona, center, join Morgan Downey, right, at the STOP Obesity Alliance panel discussion at the Newseum in September. 

The recommendations of the group will provide policymakers guidelines in dealing with obesity in forthcoming reform bills. STOP Obesity Alliance 

Richard H. Carmona, M.D., M.P.H., STOP Obesity Alliance Health & Wellness Chairperson, 17th Surgeon General of the United States (2002-2006) 

David Satcher, M.D., M.P.H., The Satcher Leadership Institute Director, 16th Surgeon General of the United States (1998-2002) 

Jeff Levi, Ph.D., Trust for America’s Health 

Christine Ferguson, J.D., STOP Obesity Alliance Director. 

Helen Darling, National Business Group on Health 

August 11, 2009

President Obama calls for health insurance reform to cover obesity treatments, stating, “All I’m saying is let’s take the example of something like diabetes, one of — a disease that’s skyrocketing, partly because of obesity, partly because it’s not treated as effectively as it could be. Right now if we paid a family — if a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they’re taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that’s $30,000, $40,000, $50,000 — immediately the surgeon is reimbursed. Well, why not make sure that we’re also reimbursing the care that prevents the amputation, right? That will save us money. Text – Obama’s Health Care Town Hall in Portsmouth – NYTimes.com

July 27-29

Centers for Disease Control and Prevention hold Weight of the Nation Conference in Washington, D.C. Speakers include former President Bill Clinton and HHS Secretary, Katherine Sebelius. For full conference information go to CDC Features – Weight of the Nation

July 12, 2009

From Morgan Downey: The ways in which health care reform can address obesity

1. Prevalence of Obesity in Uninsured Population

There appears to be a high prevalence of overweight and obesity in the uninsured population. A study published in 2000, indicated that, “Smokers, obese individuals, and binge drinkers, were more often uninsured than adults without these risk factors. In contrast, people with self-reported hypertension, diabetes mellitus, and elevated cholesterol were less likely to be uninsured than adults without these conditions.” Ayanian, JZ, Weissman, JS, Schneider EC, Unmet Health Needs of Uninsured Adults in the United States, JAMA, 2000;284:2061-2069. Free full text at Unmet Health Needs of Uninsured Adults in the United States — Ayanian et al. 284 (16): 2061 — JAMA

Likewise, it is estimated that nearly half of all uninsured, non-elderly adults report having a chronic condition. Common reported chronic conditions are diabetes, hypertension, arthritis-related conditions, high cholesterol, asthma and heart disease, all of which are either caused by or highly associated with, overweight and obesity. “Uninsured American with Chronic Health Conditions: Key Findings from the National Health Interview Survey, Uninsured Americans With Chronic Health Conditions: Key Findings from the National Health Interview Survey – RWJF

2. Limiting Use of Pre-Existing Conditions

When individuals, outside of group plans, with obesity try to purchase health insurance policies on an individual basis, they find they are unwelcome. Many private health insurance programs exclude individuals with certain Body Mass Index from accessing individual policies. According to F as in Fat report by the Trust for America, many companies will charge additional premiums for persons with a BMI between 30 and 39. Over a BMI of 39, a person may find no company willing to provide individual coverage. Other plans may classify persons as “unhealthy” or “uninsurable” due to obesity. Companies are free to make their own definitions of these terms. Few states restrict these practices. 14-14 (See F as in Fat: How Obesity Policies Are Failing in America 2008 – RWJF)

Even if the person with obesity can overcome the weight hurdle, their coverage may be limited by the use of the common ‘pre-existing condition’ requirements which restrict a person for a period of time from accessing their plan’s benefits. As indicated above, many chronic diseases are associated with obesity and these can form additional hurdles to obtaining needed care.

Some health insurance plans have started to take very small steps to deal with obesity. For the most part, these efforts include bariatric surgery for additional premiums or offering employer’s a worksite wellness program, also for an additional payment.

Finally, few states have any kind of mandated benefits related to obesity treatment or prevention. In such cases, the insurance industry typically fights such proposals extremely vigorously. (See statement of Bob Clegg former Republican majority Senate leader, New Hampshire at The Challenge of Obesity for Policy Makers: Recommendations for the Next Administration: Republican Convention Forum – health08.org)

1. Coverage of Obesity Interventions

Once insured the question arises, “Will offered health plans address obesity prevention and treatment?” If the uninsured health plan does not address the, or one of the, root cause of an individual’s health concerns, will any progress be made in using this entire health reform effort to improve individual and public health? The current situation of health insurance, in its avoidance of obesity prevention and treatment, perpetuates a focus on the conditions caused by obesity. Millions spent on heart disease or type 2 diabetes (not to mention the other ill effects, see above) will only continue. Only by addressing the root problem will Americans and America’s health see improvement.

The question has been raised of using the Medicare and Medicaid coverage criteria as the model for the legislation’s covered services. In terms of obesity, these programs cover obesity treatment and prevention inconsistently and inadequately. Regarding Medicare,

1. In 2004, Medicare eliminated language in its coverage manual to the effect that obesity was not a disease. This opened the door to treat obesity in its own right as a disease.
2. In February 2006, CMS significantly expanded its national coverage policies to cover more bariatric surgery procedures when performed in designated centers of excellence.
3. Medicare Part D does not cover drugs for the treatment of obesity.
4. Medicare does not cover physician or dietetic counseling for weight loss.

Regarding Medicaid,

1. Most Medicaid plans have no to limited coverage of drugs for the treatment of obesity. The Medicaid statute actually bans states from including such pharmaceutical products but allows a waiver on request of the state. Few states have sought or received such a waiver.
2. Bariatric surgery, while nominally covered in many states, is subject to such low reimbursement rates that few surgeons want to provide it. Other limitations on is provision further limit its ability to help individuals who meet the NIH recommendations from receiving the surgery.

The Internal Revenue Service, through a change in a revenue ruling in 2000, allows individuals to deduct the costs of weight loss programs upon recommendation of a physician. Of course, taxpayers must meet the threshold of 7.5% of adjusted gross income to qualify for the medical deduction at all. Therefore, Congress should use the expert, evidence-based recommendations of the NIH to decide covered services. (See, http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf)

Similar recommendations adopted by the American Academy of Pediatrics and 15 national medical societies should be adopted by children and adolescents as indicated. (See, Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report — Barlow and and the Expert Committee 120 (4): S164 — Pediatrics)

The Baucus Plan (Call to Action Health Reform 2009, November 12, 2008, Senate Finance Committee) would leave coverage decisions to a new independent health coverage council. This is probably insufficient and Congress should make this decision on coverage of obesity interventions, both prevention and treatment, itself. This would be consistent with the Baucus Plan’s goal, “Prevention must become a cornerstone of the health care system rather than an afterthought. This shift requires a fundamental change in the way individuals perceive and access the system and community-based wellness approaches at the Federal, state, and local levels. With a national culture of wellness, chronic disease and obesity will be better managed and, more importantly, reduced.” (See, http://finance.senate.gov/healthreform2009/finalwhitepaper.pdf (at p. 28)

5. Eliminating the Itemized Deduction

As mentioned earlier, in 2000, the Internal Revenue Service issued a revenue ruling allowing the expenses for weight control which were recommended by a physician to be deductible as a medical expense. While the scope of this ruling is constrained by the limitation that such expenses must exceed 7.5% of adjusted gross income, it is nevertheless the only federal financial support for treatments for obesity outside of the Medicare coverage of bariatric surgery (which is limited to Medicare elderly and non-elderly disabled populations). As such, it should not be modified or repealed unless Congress mandates the benefit package described above.

6. Taxing Sugar-sweetened beverages

The role of sugar sweetened beverages in the increase of obesity, particularly childhood obesity, has been well documented. The evidence from epidemiological and experimental studies indicates that a greater consumption of sugar sweetened beverages is associated with weight gain and obesity.( See, Malik VS, Schulze MB, Hu FB, Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr 2006;84:274-88. Intake of sugar-sweetened beverages and weight gai…[Am J Clin Nutr. 2006] – PubMed Result) Replacing sugar sweetened beverages with water could result in an average reduction of 235 calories per day. ( See, Wang YC, Ludwig DS, Sonneville K, Gortmaker SL, Impact of changes in sweetened caloric beverage consumption on energy intake among children and adolescents. Arch Pediatr Adolesc Med 2009 Apr; 163(4):336-43.Impact of change in sweetened caloric beverage con…[Arch Pediatr Adolesc Med. 2009] – PubMed Result)

The Senate Finance Committee options, however, do not indicate the level of taxation under consideration. Only a significant tax level is likely to affect consumption and its effect on obesity is predicated on the sugar sweetened beverage not being replaced by foods or beverages of similar caloric value. A significant tax, however, is likely to presage decline in consumption over time with an accompanying decline in tax revenue over that time. Therefore, its contribution to financing tax reform would be offset by its value in reducing obesity. As no state or jurisdiction has undertaken this policy option, there is no way of knowing with some certainty whether obesity levels would fall. This may not be a reason not to impose such a tax.

8. Tax on ‘Cadillac Plans’

Also, proposals have been made to treat as income to employee the costs of “Cadillac” health insurance plans, i.e. those that have extensive benefit packages, very low co-payments or deductibles or both. In regard to obesity, probably most of the health insurance plans which now cover surgery, drugs and behavioral modification for persons with obesity would be regarded as such a plan. To tax the employee for these benefits may undo the goals of obesity prevention and reduction. The time has come for employers and payors to provide comprehensive coverage of obesity treatments. Enactment of a tax on the extra costs of such plans is likely to have a negative effect. (See, Swallowing the Cost of Obesity Treatment | workforce.com)

April 21, 2009

Somerville MA tagged as model for health care reform Mass. town takes steps to trim fat (really), health care costs – USATODAY.com

March 5, 2009

Obama addresses obesity at close of national health care forum The White House – Press Office – Closing Remarks by the President at White House Forum on Health Reform, followed by Q&A, 3/5/09

Feb 4, 2009

President Obama Signs SCHIP Bill, Includes Childhood Obesity Demonstration Project.

The new SCHIP legislation contains a requirement for the Secretary of HHS in consultation with the Centers for Medicare and Medicaid Services to conduct a “systematic model for reducing childhood obesity.” The model is intended to identify behavioral risk factors for obesity through self-assessment, identify, through self-assessment, needed clinical preventive and screening benefits among children identified as target individuals on the basis or such risk factors and provide ongoing support to such individuals to reduce risk factors and promote use of preventive and screening benefits and “be designed to improve health outcomes, satisfaction, quality of life, and appropriate use of items and services available under Title 19 (Medicaid) or Title 21.

November 30, 2008

CEO’s Talk Up Obesity CEOs’ Healthcare-Reform Priorities: Obesity and Tort Reform, But Not Universal Coverage | BNET Healthcare Blog | BNET

August, 2008

For the first time in history, the two major political parties in the United States recognized the importance of obesity in their respective party platforms

Democratic Party Platform addresses obesity

The Democratic Platform, adopted in Denver, Colorado on 25 August 2008, refers to obesity three times:

“Our nation faces epidemics of obesity and chronic diseases as well as new threats like pandemic flu and bioterrorism. Yet despite all of this, less than four cents of every health care dollar is spent on prevention and public health.” (p

“An Emphasis on Prevention and Wellness. Chronic diseases account for 70 percent of the nation’s overall health care spending. We need to promote healthy lifestyles and disease prevention and management especially with health promotion programs at work and physical education in schools. All Americans should be empowered to promote wellness and have access to preventive services to impede the development of costly chronic conditions, such as obesity, diabetes, heart disease, and hypertension.” (p 9)

“Public Health and Research. Health and wellness is a shared responsibility among individuals and families, school systems, employers, the medical and public health workforce and government at all levels. We will ensure that Americans can benefit from healthy environments that allow them to pursue healthy choices. Additionally, as childhood obesity rates have more than doubled in the last 30 years, we will work to ensure healthy environments in our schools.” (p 10)

A forum on obesity was held by the Obesity Society. The forum at the Democratic National Convention, held on 25 August 2008 at the Denver Art Museum, featured Gary Foster, president, James Hill and Robert Eckel of the University of Colorado, past presidents, and Caroline Apovian with Melody Barnes, Director of Policy for the Obama for President Campaign, and Karen Kornbluh, principal author of the 2008 Democratic Party Platform. Also presenting were Congressman and chairman of the Congressional Black Caucus John Conyers (D-MI-14), Jim Rex, Superintendent of Education in South Carolina and R.T. Rybak, Mayor of Minneapolis, Minnesota. Sally Squires, former columnist for the Washington Post and founder of the Lean Plate Club, moderated the event. Discussions ranged far and wide about expanding treatment and improving prevention of obesity, especially the role of schools in childhood obesity.

The Republican Party Platform, adopted a week later in St Paul, Minnesota, provides:

“Prevent Disease and End the ‘Sick Care’ System. Chronic diseases—in many cases, preventable conditions—are driving health care costs, consuming three of every four health care dollars. We can reduce demand for medical care by fostering personal responsibility within a culture of wellness, while increasing access to preventive services, including improved nutrition and breakthrough medications that keep people healthy and out of the hospital. To reduce the incidence of diabetes, cancer, heart disease and stroke we call for a national grassroots campaign against obesity, especially among children.”

On 2 September 2008, The James L. Hill Research Library in St Paul, Minnesota, was the scene of the Republican forum. Speakers included Caroline Apovian, Eric Finkelstein, and Michael Jensen, also a past president of the Society. Allen Levine and Charles Billington (another past president) presented welcoming statements from the University of Minnesota. Lesley Stahl, correspondent on CBS News’ 60 Minutes, moderated a panel consisting of former Secretary of Health and Human Services, Tommy Thompson, representing the campaign of Senator John McCain, former Presidential candidate and Arkansas Governor, Mike Huckabee and State Senator Bob Clegg of New Hampshire. Huckabee enthralled the audience with accounts of trying to get attention to health care issues and obesity in the presidential debates and within his own party. Bob Clegg told his personal story of his fight with obesity and subsequent bariatric surgery. Clegg was the Republican majority leader in the New Hampshire State Senate, and push through the legislature, a bill mandating insurance companies cover bariatric surgery. His personal story combined with the legislative maneuvering was compelling.

Video and transcript of Republican National Convention Forum is available at: http://www.kaisernetwork.org/
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Video and transcript of Democratic National Convention Forum is available at: http://www.kaisernetwork.org/
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The video and transcript of the 19 September 2007 forum on what the next administration should do can be found at: http://www.kaisernetwork.org/
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