Open enrollment for the state health insurance exchanges created under the Affordable Care Act (ACA) begins in October. How much do you know about the Affordable Care Act and what it means for obesity treatments including metabolic and bariatric surgery? The American Society for Metabolic and Bariatric Surgery(ASMBS) Secretary Treasurer and former Access to Care Committee Chair John Morton, MD, says the answer depends on where you live. Although obesity is a national epidemic that knows no boundaries, obesity treatment under ACA is largely being handled at the state level.
Which States Will Cover Obesity Treatments?
One of the key components of the ACA is a mandate that state health exchanges cover a set of health care service categories it has defined as Essential Health Benefits (EHB). Categories include ambulatory patient services, prescription drugs, and chronic disease management, among others.
It is expected 23 states will have obesity treatments including metabolic and bariatric surgery as part of its EHB, and five will also cover weight-loss programs. However, 27 states and Washington, D.C. currently have no plans to include it. View a chart of the exchange programs for each state.
"There is a real geographic disparity," said Dr. Morton. "And it’s sad to say that many of the states expected to exclude obesity treatments can be found in the south, where the highest rates of obesity can also be found. We are working very hard to change the equation so that all people with obesity, no matter where your home happens to be, can have access to evidence-based prevention and treatment programs."
Even in those states that exclude metabolic and bariatric surgery in their exchanges, many obesity experts see a silver lining for a country where two-third its population is overweight or obese. ACA calls for coverage of obesity screening and counseling, regardless of what obesity treatments are covered or not covered.
Obesity Screenings and Counseling
All private insurance plans starting in 2014 must cover intensive behavioral counseling for obesity in adults. That’s about 56 million people with obesity. It is anticipated that 3.7 million Americans with obesity will 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. So one of the current FDA approved drugs for obesity should be available, according to The Downey Obesity Report.
Screening and counseling for obesity has to be covered with no patient cost-sharing (co-payments, co-insurance or deductibles) by most insurers under the preventive services benefit of the Affordable Care Act, says Susan Pisano, a spokeswoman for America’s Health Insurance Plans, the national trade association representing the health insurance industry. Medicare is already covering this service.
Plans vary widely in what they will do. Some insurers are offering telephone counseling, others cover visits with a health coach, and some cover group sessions that offer lifestyle advice. Some are even referring patients to Weight Watchers.
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Healthcare.gov What is the Health Insurance Marketplace
U.S. Department of Health and Human Services The Affordable Care Act
Connect - The Official News Magazine of the ASMBS - The Affordable Care Act and You
Healthcare.gov Essential Health Benefits
The Downey Obesity Report - Obesity and Obamacare: A Practical Guide