Shots - Health News
12:31 am
Mon May 27, 2013

For Many, Affordable Care Act Won't Cover Bariatric Surgery

Originally published on Tue May 28, 2013 1:00 pm

Uninsured Americans who are hoping the new health insurance law will give them access to weight loss treatments are likely to be disappointed.

That's especially the case in the Deep South, where obesity rates are among the highest in the nation, and states will not require health plans sold on the new online insurance marketplaces to cover medical weight loss treatments like prescription drugs and bariatric surgery.

Dr. Erin Cummins directs the bariatric surgery department at Central Mississippi Medical Center in the state capital of Jackson. She grew up in the Delta, her husband is a cotton farmer, and although she's petite and fit, she understands well enough how Mississippians end up on her operating table.

"You have to realize in the South, everything revolves around food. Reunions, funerals, parties — everything revolves around food," Cummins says.

That long-standing food culture, as well as other factors like inactivity and poverty, have saddled Mississippi with the highest obesity rate in the nation.

Doctors here are no longer surprised to see 20-somethings with diabetes, hypertension, sleep apnea, heart disease and severe joint pain. And the prevalence of severe and super-obesity is growing rapidly. For those patients, bariatric surgery is considered the most effective treatment to induce significant weight loss.

Cummins describes the procedure: "We're restricting the stomach size to where a patient isn't going to eat as much. Then we reroute the intestines a little bit and realign it to delay digestion, so to speak, to bypass it. So everything a patient eats in a gastric bypass is not going to be absorbed."

After surgery, many of the complications of obesity, like sleep apnea and high blood pressure, are reversed. Multiple studies have found that about 80 percent of diabetics can stop medication in the first year.

Medicare and about two-thirds of large employers cover bariatric surgery in the U.S. But the procedure is pricey — an average of $42,000 — and many small employers, including those in Mississippi, don't cover it.

When the Affordable Care Act became law in 2010, one goal was to erase those sorts of regional variations in access.

"Our hope was that there would be a single benefit for the entire country, and as part of that benefit there would be coverage for obesity treatment," says Dr. John Morton. He is director of bariatric surgery at Stanford University Morton, and has led national and state lobbying efforts to get insurance coverage for the surgery.

But amid worries that a uniform set of benefits would be too expensive in some states, and sensitive to the optics of the federal government laying down one rule for all states, the U.S. Department of Health and Human Services changed course. It decided instead to match benefits to the most popular small group plan sold in each state, in essence reflecting local competitive forces.

That's led to an odd twist: In more than two dozen states, obesity treatments – including intensive weight loss counseling, drugs and surgery – won't be covered in plans sold on the exchanges.

Bariatric surgery won't be covered on the exchanges in Alabama, Louisiana, Arkansas, Texas and Mississippi. That's where, according to the Centers for Disease Control, obesity rates are among the highest.

Morton applauds the growing awareness around obesity prevention in the U.S., but, he says, some 15 million Americans who are already severely obese still need medical treatment.

"If they don't have insurance, they're not going to get the therapy," Morton says. "We see cancer therapy covered routinely. We see heart disease covered routinely. Why is it that we don't see obesity coverage routinely?"

Therese Hanna, Executive Director of the Center for Mississippi Health Policy, isn't surprised that obesity treatments are excluded on the insurance exchange in her state. She says it all has to do with keeping cost down for many people who will be buying insurance for the first time.

"With the discussions around what should be covered under the exchange within the state, a lot of it had to do with balancing cost versus the coverage," says Hanna.

Mississippians who buy insurance on the exchange, Hanna says, will likely be the cashiers, cooks, cleaners and construction workers that make up much of the state's uninsured. And even though many of them will qualify for federal subsidies, the price of monthly premiums must be kept low.

"If you try to include everything, the cost would be so high that people wouldn't be able to afford the coverage, so you defeat the purpose," Hanna says. The discussion in Mississippi, she says, has focused on providing care for things like high blood pressure, diabetes and heart disease. "So we have a lot of needs to be covered other than obesity itself."

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.

Transcript

DAVID GREENE, HOST:

This is MORNING EDITION from NPR News. I'm David Greene. Steve Inskeep is on assignment in Syria.

Today in Your Health, we look at a new study showing that patients fighting obesity are more like to shop around for their doctors. That story in a moment. First, how the new federal health law falls short when it comes to treating obesity, which is among the nation's leading health problems.

Rising obesity rates bring with it an increase in diseases like diabetes and heart disease. And for people who are suffering from severe obesity, weight-loss surgery is often considered the most effective treatment. Nowhere is obesity more prevalent than in the state of Mississippi. But a quirk in the Affordable Care Act means Mississippi and other Southern states will not be covering weight-loss surgery in the new insurance marketplaces called Exchanges.

Sarah Varney reports.

SARAH VARNEY, BYLINE: Deep in the Mississippi Delta, the town of Belzoni claims to be the Catfish Capital of the World, a point that's hard to miss with the human-size catfish sculptures standing on their tails along Main Street. A handwritten chalkboard propped up on the sidewalk announces today's lunchtime special at the Greasy Row Grill: fried pork chops. Inside is Chris Boykin, the grill's fresh-faced owner.

CHRIS BOYKIN: We just cook up some food, man, some home cooking. We got fried green beans, fried cheese sticks, a lot of fried.

VARNEY: Fried mushrooms, fried crawfish tails, fried pickles - which are my favorite - and fried catfish.

(SOUNDBITE OF SIZZLING)

VARNEY: An arm's throw away from the diner is a medical clinic run by Dr. Carlton Gorton.

DR. CARLTON GORTON: That's the way we cook a lot down here. And so, people don't necessarily understand that when you fry, it has a lot more calories, a lot more salt intake. And so they're really not associating the two. They're just associating that we're getting together. This is how we've always done it. This is how grandmamma did it. This is how her mama did it.

DR. ERIN CUMMINS: You ready for surgery?

UNIDENTIFIED WOMAN: Mm-hmm.

CUMMINS: You ready to change your life?

UNIDENTIFIED WOMAN: Yes.

CUMMINS: You ready to get your life?

UNIDENTIFIED WOMAN: Mm-hmm.

CUMMINS: Good. Good. Good. And this is...

VARNEY: Down in the state capital of Jackson, at Central Mississippi Medical Center, Dr. Erin Cummins greets a heavy-set patient in a cramped hospital room who is being prepped for gastric bypass surgery.

CUMMINS: When you wake up, it'll all be over. She stays in recovery room for two to four hours depending on how she's doing...

VARNEY: Cummins oversees bariatric surgery here. She grew up in the Delta. Her husband is a cotton farmer. And although she's petite and fit, she understands well enough how Mississippians end up on her operating table.

CUMMINS: You have to realize in the South, everything revolves around food. Reunions, funerals, parties, everything revolves around food.

VARNEY: That longstanding culture and factors like inactivity and poverty, have saddled Mississippi with the highest obesity rate in the nation. Doctors here are no longer surprised to see severely obese 20-somethings with diabetes, hypertension, sleep apnea, heart disease and severe joint pain. For many, surgery is considered the most effective treatment to induce significant weight loss.

CUMMINS: So we're restricting the stomach size to where a patient is not going to eat as much. Then we re-route the intestines a little bit and realign it to delay digestion, so to speak, sort of bypass it.

VARNEY: After surgery, many of the complications of obesity, like sleep apnea and high blood pressure, are reversed. Multiple studies have found that 80-to-85 percent of diabetics can stop medication in the first year. But the procedure is pricey, at an average of $42,000. Medicare and two-thirds of large employers cover it. But many small employers, including those in Mississippi, don't.

And that decision is setting the course for the roll out of the Affordable Care Act early next year.

DR. JOHN MORTON: Our hope was that there would be a single benefit for the entire country, and as part of that benefit there would be coverage for obesity treatment.

VARNEY: Dr. John Morton is director of bariatric surgery at Stanford University, and has led his surgical association's national and state lobbying efforts. He says at first, federal health officials considered one national standard of benefits sold on the insurance exchanges. But amid cries to give states more say, those standards now mirror the insurance plans already sold in each state. That's led to an odd twist.

In more than two dozen states, obesity treatments - including intensive weight loss counseling, drugs and surgery - won't be covered. That includes Alabama, Louisiana, Arkansas, Texas and Mississippi where, according to the Centers for Disease Control and Prevention, obesity rates are among the highest.

Morton applauds the growing awareness around obesity prevention, but he says the some 15 million Americans who are already severely obese need medical treatment.

MORTON: If they don't have insurance they're not going to get the therapy. We see heart disease covered routinely. Why is it that we don't see obesity coverage routinely?

VARNEY: In Jackson, Mississippi, Therese Hanna isn't surprised that obesity treatments are excluded in her state. Hanna, Executive Director of the Center for Mississippi Health Policy, says it all has to do with keeping cost down.

THERESE HANNA: With the discussions around what should be covered under the exchange within the state, a lot of it had to do with balancing cost versus the coverage, and that's really a different area than if you look at it from the standpoint of if we want to attack obesity, what is it that we need to pay for?

VARNEY: Hanna says Mississippians who buy insurance on the exchange will likely be the cashiers, cooks, cleaners and construction workers that make up much of the state's uninsured.

HANNA: If you try to include everything, the cost would be so high that people wouldn't be able to afford the coverage, so you defeat the purpose. And that's been most of the discussion in our state is how do we provide the kind of care for things like high blood pressure, diabetes and heart disease. So we have a lot of needs to be covered other than obesity itself.

VARNEY: Family physicians, pediatricians, nutrition counselors and others in Mississippi seem fatigued by the obesity epidemic and the cascade of health problems it causes. Still, while there is weariness on the front lines, Mississippians know how to live a rich life.

(SOUNDBITE OF MUSIC)

VARNEY: A live Blues band takes the stage on a Monday night at Hal & Mal's, a Jackson institution decorated with tasteful Elvis paintings. A birthday girl is walking around with dollars bills pinned to her blouse. She's turning 62 years old, and her friends invite everyone into the back room to celebrate. The table is laid out thoughtfully, with a crock-pot of melted cheese and hamburgers sliders and available on the menu: golden-fried dill pickles.

For NPR News, I'm Sarah Varney.

GREENE: Sarah Varney with our partner at Kaiser Health News, a non-profit news service. Transcript provided by NPR, Copyright NPR.