Understanding Obesity as Both a Disease and a Public Health Problem: A Case for More Comprehensive Health Insurance Coverage of Obesity Treatments in Maryland’s and Virginia’s Public and Private Markets

Abstract

On June 18th of 2013, the American Medical Association (AMA) officially resolved to classify obesity as a disease, representing a momentous departure from its previous designation as a “major public health problem.” In support of their resolution, the AMA House of Delegates framed obesity according to medically established criteria for disease identification, maintaining that obesity constitutes an “impairment of the normal functioning” of the body; possesses “characteristic signs and symptoms”; produces considerable morbidities; and increases mortality risk. Using the AMA resolution as grounding, this thesis explores the status and implications of coverage of obesity treatments in Maryland’s and Virginia’s public and private markets, contextualizing present realities and future projections of said coverage in the changing landscape of health care reform offered by the Affordable Care Act. Currently, coverage of the two predominant categories of obesity treatment – behaviorally based weight-loss assistance and bariatric surgery – is variable according to state. While the federally administered Medicare program for seniors ensures coverage of bariatric surgery and weight-loss assistance for all its beneficiaries, state-administered Medicaid programs differ considerably in what they offer. According to recent analysis, 47 state Medicaid programs cover bariatric surgery, while only 26 cover weight-loss assistance. State legislation on private coverage for individual and small-group plans is comparably variable – 22 states now cover bariatric surgery as an essential health benefit (EHB), while only four states cover weight-loss assistance.1 In the coming years, perhaps no two states will more valuably demonstrate the ramifications of this benefit differentiation than Maryland and Virginia. Within its Medicaid program and private individual and small-group plans, Maryland covers bariatric surgery as an EHB, but not weight-loss assistance. While Virginia has classified neither treatment as an EHB in its private market, its Medicaid program covers both bariatric surgery and weight-loss assistance. In the media, there is a prevailing assumption that Maryland, in providing more widespread coverage of bariatric surgery and presumably subscribing to the AMA’s “disease” label, will be better equipped to confront its obesity problem. Bariatric surgery, to be sure, remains the most effective intervention for morbid obesity, helping patients lose over 50 percent of their excess body weight and significantly reducing their risk of chronic disease. Because of the procedure’s exorbitant price tag, however, it is generally recommended for only the very obese. With this in mind, some fear that states’ coverage of bariatric surgery will result in overtreatment of obese individuals whose symptoms make them better suited for equally effective and less expensive behaviorally based interventions. In what follows, this thesis makes the case for state coverage of both bariatric surgery and weight-loss assistance in states’ public and private markets, discrediting the notion of Maryland’s “superior” policy. As it argues for more inclusive (albeit realistic and restrictive) coverage of obesity treatments, it urges states to assume an approach that tackles the whole spectrum of obesity treatment, so that states can more effectively address the problem at all stages and from all angles. Ultimately, in exploring the features of American society that have produced an environment conducive to obesity, it encourages adoption of a more balanced understanding that interprets obesity as both a disease and a public health problem.