Repealing Obamacare: read the fine print

January 10th, 2017 No comments »

Washington is preparing a re-start of the 8 year battle over Obamacare, formally the Affordable Care Act (ACA). With Republicans in control of both Congress and the White House, it is widely expected that they will have to live up to their promise to repeal the law. But repeal is not as easy as it sounds. The ACA is a large and complicated law embedded not only in the health care system but more widely in American life.

Many aspects of the repeal effort will be hotly debated in the near future. Behind the headlines will be the details, where, as we know, the devils reside. Take two important issues: coverage of persons with pre-existing conditions and employer wellness programs. President-elect Trump and many Republicans have promised to continue the ACA’s provision that pre-existing conditions cannot be used as a basis for denial of insurance coverage. But the ACA’s provision has a second element: insurers cannot charge more for covering persons with pre-existing conditions. (Obesity and related conditions are considered “pre-existing” conditions.) However, a proposed repeal bill developed by the House of Representative Republican Study group would provide coverage for pre-existing through state high-risk insurance pools. Premiums could go up to 200% of the average premium charged in a state. Clearly, such premiums would make policies unaffordable by many with chronic health conditions, especially without subsidies for low-income Americans as provided for in the ACA.

If one took repealing the ACA literally, we could assume that its provisions relating to employer wellness programs would be eliminated. If repealed, the maximum reward/penalty would revert from 30% of the total employer-employee to the previous level of 20% established by ERISA. Wrong.  Under the Republican Study Group, the maximum would actually increase to 50% from 30%.  The Republican Study Group may be one of the more conservative proposals we will see but it provides an important lesson: read the fine print.

Medicaid and the obesity population

July 13th, 2016 No comments »

A recent study indicates that midlife obesity predicts nursing home admissions. This could be critical for Medicaid which pays the majority of nursing home costs.  Overweight was not associated with greater nursing home admissions. Discrimination may be the reason. See post. Recent data show a 24.2% of nursing home residents take antipsychotic medications which can cause weight gain. 5.8% or residents show unintended weight loss.

2016 State Medicaid coverage of fee-for-service obesity treatments

May 2nd, 2016 No comments »

The STOP Obesity Alliance has updated its state-by-state information on fee-for-service obesity treatments in the Medicaid program. See here.

The Impact of Obesity on Medical Imaging

December 17th, 2014 No comments »

Anyone going to a hospital recently knows that medical imaging, X-rays, PET scans, MRIs, etc, are a critical component of diagnostic medicine. So what happens when more and more patients have obesity or severe or morbid obesity? Raul N. Uppot and colleagues have described many of the problems faced by radiologists. The issues include: transporting the patient with severe obesity, fitting the patient on the imaging equipment, the diagnostic quality of such images, and, how is the imaging industry responding with equipment designed for the patients with obesity?


Fast Food Giants Target Obese-Prone Children

November 13th, 2014 No comments »

The Washington Post Wonkblog carries an article on research from Arizona State University’s Punam Ohri-Vachaspati which found that fast-food chains are targeting children already at high risk for obesity, including African-Americans, poor and those in rural areas.


Childhood Obesity Crisis Over?

February 20th, 2014 No comments »

On January 28, 2014, President Barack Obama said in the State of the Union speech,” As usual, our First Lady sets a good example.  Michelle’s Let’s Move partnership with schools, businesses, and local leaders has helped bring down childhood obesity rates for the first time in thirty years – an achievement that will improve lives and reduce health care costs for decades to come. “ Really? We’ve already reviewed Michelle Obama’s premature “Mission Accomplished”. Perhaps the President and First Lady should take note of recent research which indicate the childhood obesity crisis is far from over.

Just two days after the State of the Union, the New England Journal of Medicine published a study by Cunningham and colleagues, “Incidence of Childhood Obesity in the United States.” Much attention has been paid to the prevalence of obesity, meaning the total number of persons with the condition in the population. Incidence, on the other hand, is the number of new cases appearing in the population at a given time. So Cunningham et al, looked at a database of 7,738 children who were in kindergarten in 1998 and were measured 7 times between 1998 and 2007.

They found that, on entering kindergarten (age 5.6 years) 12.4% were obese and another 14.9% were overweight. In eighth grade (age 14.1 years) 20.8% were obese and 17% were overweight. The incidence dropped between fifth and eighth grade. Overweight 5-year-olds were four times as likely as normal weight children to become obese. Among children who became obese between 5 and 14, nearly half had been overweight and 75% were above the 70th percentile. Hispanic and non-Hispanic black children had higher rates of obesity than white children. Children from the wealthiest 20% of families had the lower prevalence of obesity in kindergarten than those in all other socioeconomic groups and this difference increased through the eighth grade.

Overweight kindergartners had 4 times the risk of becoming obese by age 14 as normal weight kindergartners. Overweight children from the two highest socioeconomic groups had five times the risk of becoming obese as normal-weight children of similar socioeconomic status.

The incidence of obesity between the ages of 5 and 14 years was 4 times as high among children who had been overweight at age of 5 as among children who had a normal weight at that age. The researchers’ findings are significant in addressing public policies regarding obesity. “First,” they state, “a component of the course to obesity is already established by age of 5 years…Second, obesity incidence among overweight children tended to occur early in elementary school. “ The study supports closer examination of the roles of the early-life home and pre-school environments, intrauterine factors and genetic predisposition.

(Although not discussed in the paper, age 5-6 is regarded as the time of a child’s lowest Body Mass Index (BMI) and the beginning of “adiposity rebound” – a period of increasing weight into adulthood. This is a normal phenomenon all children go through.)

New studies show how babies might be already programmed for excessive weight gain. One study, by Jane Wardle and colleagues, show that greater appetite (either due to higher food responsiveness or lower satiety responsiveness predicted rapid growth up to 15 months of age among twins. The second study by the same group showed that low satiety responsiveness is one of the mechanisms by which genetic predisposition leads to weight gain in an environment rich with food.

Employer Wellness Issue Heats Up

May 20th, 2013 No comments »

The Equal Employment Opportunity Commission (EEOC) held a long hearing on May 8, 2013 on employer wellness programs. Opponents made a strong case that there was virtually no way that a mandatory health-contingent wellness plan could not discriminate against protected classes of workers. (See statement of Judith Lichtman) On the other hand, the more pro-business representatives argued that Congress and the Administration supported the changes in the Affordable Care Act and the programs where here to stay. It seems that all parties are urging the EEOC to provide guidances to employers.

The testimony came amid a backdrop of waiting for the final regulations from the Obama Administration. The comment period closed in January and many were expecting we would have final regulations by now. Politico reported that a group of corporate CEOs with the Business Roundtable were in Washington recently to lobby the Administration to avoid further weakening of the regulations.

Forbes magazine was reporting the CVS-Caremark was penalizing workers $600 annually if they failed to complete a health risk assessment. The article noted that most companies did not provide such stiff penalties but many were moving in that direction.

Meanwhile, several research articles provide only lukewarm support for weigh loss employer wellness programs.

A Health Affairs article by Ron Goetzel and colleagues, found only 22 % of employer health care costs could be attributed to 10 modifiable health factors (including obesity). This is actually a drop from 24.9% in 1998, even though rates of obesity have increased and costs related to obesity have gone up. Obesity contributed the most excess costs at $347 per capita. Goetzel, Pei, et al,

Another recent paper was a longitudinal study at the worker productivity in terms of absenteeism, presenteeism and job performance associated with changes in 19 modifiable well-being risks. These included physical health risks, health behavior risks, social and emotional health risks work-related risks and financial health risks.  The researchers found that, “Obesity, high cholesterol, tobacco use and excessive alcohol generally contributed to productivity changes insignificantly or unfavorable, possibly because of its multicolinearity with other risks that are closely correlated.” However, they noted that, “Health-related risk explained only a portion of the total productivity variances. For example, Riedel et al found that health risks accounted for 7.8% of the total variance in productivity impairment and acknowledged that the majority of the variation was left unexplained. Lenneman et al also found only 8.5% of the variance in productivity was contributed by health risks…We found that reductions in work-related well-being risks and financial health risks significantly contributed to improvement in productivity measures especially for measures of presenteeism and job performance that were not attributable solely to the more narrow definition of physical health.” They found modest numbers of workers were able to make improvements: 25% reduced their physical health risks 26% improved their health behaviors 16% improved their social and emotional health, 31% improved their work-related risks and 13% their financial health risks. Improvements in absenteeism, decrease in presenteeism and a modest improvement in job performance accompanied such changes. They calculated these improvements were equivalent to a savings of $468 per person per year. Shi, et al.

Ted Kyle reports in his blog that one program, Healthy Blue Living, requires obese participants to wear a pedometer which uploads their physical activity to the employer wellness program. The employees must meet daily step goals if they want to keep full health benefits. Not doing so could cost them each $2000 a year. Kyle notes (and I strongly agree) that this constitutes human experimentation without the protection of the federal regulation protecting human subjects, 45 Code of Federal Regulations Part 46. In fact, the program is not that successful. Promotional material notes that only 16% who agreed got their weight under a BMI of 30.

Yet another study published in Health Affairs looked at one hospital system’s wellness program. The program provide a substantial incentive/penalty for participation in a health risk assessment (which included automated feedback) signing a health pledge, health fairs and physician referrals. The study found a significant reduction in hospitalizations for conditions related to the conditions covered by the wellness program. However, there was an increase in medication costs. Combined with the costs of the wellness program and incentives, the authors concluded, “It is unlikely that the program saved money.” Gowrisankaran G, et al. A Hospital System’s Wellness Program Linked to Health Plan Enrollment Cut Hospitalizations But Not Overall Costs, Health Affairs 32 (3) 2013; 477-485. Gowrisankaran

A second paper also published in Health Affairs reviewed randomized controlled trials of workplace wellness programs. Their review raises doubts the employees with health risk factors such as obesity and tobacco use spend more money on medical care than others. They concluded that workplace wellness programs show little evidence of saving costs through health improvements without being discriminatory.  To test the assumptions of workplace wellness programs the authors, “reviewed research on the relationships among financial incentives, behavior, health status, and medical spending. We focused on randomized controlled trials involving four conditions- smoking, hypertension, high cholesterol and obesity- that are typically included in health-contingent programs. In our review, we found mixed evidence that employees with these conditions have higher health costs than other employees, which undermines the argument that employees with the conditions are particularly effective targets for incentives. We also found little evidence that working-age people change their behavior as a result of financial incentives, particularly over the long term. These findings suggest that program savings many not, in fact, derive from health improvements. Instead, they may come from making workers with health risks pay more for their health care than workers without health risks do. If true, this conclusion would jeopardize long-standing regulatory efforts, maintained in recently proposed Affordable Care Act regulations to prevent workplace wellness from being “a subterfuge for underwriting or reducing benefits based on health status. (citations omitted) Since low-income workers disproportionately suffer from conditions typically targeted by health-contingent programs, savings arising outside of health improvement may entail hidden, regressive redistributions increasing the burden imposed on low-income workers. “

In effect, they point out, wellness plans shift costs with the most vulnerable employees, those from low income groups with the most health risks probably subsidizing the healthier workers. Horwitz, JR, Kelly, BD, DiNardo, JE, Wellness Incentives in the Workplace: Cost Savings Through Cost Shifting to Unhealthy Workers, Health Affairs, 32 (3), 2013:468-476. Horwitz

The Agency for Healthcare Research and Quality (AHRQ) has issued another independent review. This time they reviewed studies of strategies to prevent weight gain in adults. The reviewers looked at 51 trials involving 555,783 subjects with at least one year of follow-up and a weight outcome. A meaningful difference between groups was considered to be 0.5 kg of weight (1.1 pound) or 1 cm of waist circumference. They found moderate evidence that workplace programs for the prevention of weight gain in adults. One study combining diet, physical activity and environmental components resulted in meaningful and statistically significant prevention of BMI change at 12 months and another that combined internet based diet and physical activity counseling resulted in significant prevention at 24 months. However, a third study found no difference. AHRQ Strategies to Prevent Weight Gain Among Adults, Comparative Effectiveness Review No. 97, AHRQ

Also cited as, Gudzune K et al Strategies to prevent weight gain in workplace and college settings: A systematic review, Prev Med. 2013 Mar 22. Gudzune


New Analysis of Medicaid Expansion

November 28th, 2012 No comments »

The Kaiser Family Foundation has issued a new report on implementation of Medicaid expansion under the Affordable Care Act. Kaiser Commission on the Uninsured and Medicaid Report