Thursday, July 15, 2004

Obesity is now an illness and can be covered by Medicare, the federal health-insurance program for the elderly and disabled.

Health and Human Services Secretary Tommy G. Thompson announced yesterday the Centers for Medicare and Medicaid Services would remove language in Medicare’s coverage manual that states obesity is not an illness.

“Obesity is a critical public health problem in our country that causes millions of Americans to suffer unnecessary health problems and to die prematurely,” Mr. Thompson said at a hearing yesterday of the Senate Appropriations labor, health and human services, and education subcommittee.

The move stops short of classifying obesity as a disease.

Sixty-four percent of the U.S. population is overweight or obese, according to the Centers for Disease Control and Prevention. Obesity contributes to diseases such as diabetes, hypertension, stroke and sleep apnea.

The change means Medicare participants may ask for reimbursement for treating excessive weight.

Anyone with a body mass index of 30 or higher is considered obese, and those with an index of 25 to 29 are considered overweight. A healthy body mass index is 19 to 25.

Patients are not guaranteed automatic coverage for treatment.

Medicare will review the requests, which could range from joining a weight-loss or fitness club to surgeries and counseling, and their rates of success before granting coverage.

Weight-loss drugs will not be covered, because the law creating the Medicare prescription program, which starts in 2006, prohibits the program from paying for those medications.

The decision to stop short of classifying obesity as a disease limits how much treatment Medicare must cover. Suggested obesity treatments must meet higher standards than medical interventions for diseases, which must be included in coverage.

By law, Medicare covers only medically necessary services for injury or illnesses. The coverage manual had stated obesity was not an illness, meaning nutritional and behavioral counseling were not covered.

Some medical conditions resulting from obesity, like diabetes, already were eligible for coverage.

CDC first requested removal of the obesity language in 2001. Now the second-biggest cause of preventable deaths in the United States, obesity contributes to 400,000 annual deaths, according to the CDC.

Obesity-related illnesses already are expanding the nation’s health care expenses and costing businesses an estimated $17 billion, according to the CDC.

“With this new policy, Medicare will be able to review scientific evidence in order to determine which interventions improve health outcomes for seniors and disabled Americans who are obese and its many associated medical conditions,” Mr. Thompson said.

Although Medicare officials said it was too early to estimate the number of requests the policy change would bring, several business groups said they are worried that the swelling number of Medicare participants eligible for the coverage will increase health insurance costs.

Small businesses probably would see the largest rate increases, said Helen Darling, president of the National Business Group on Health, a Washington nonprofit for about 219 businesses and health care insurers.

Although unions and companies with more than 500 employees are big enough to decide which health options they will cover, small businesses must buy insurance packages that have minimum coverage requirements specified by the states, Ms. Darling said.

More small businesses could drop health plans altogether if states required additional obesity coverage that push up overall rates, she said.

“Unfortunately, regulators love to put in mandates they are not stuck paying for,” Ms. Darling said.

Washington taxpayer advocacy group Citizens Against Government Waste called the decision “groundbreaking” in its implications.

“We can expect Medicare costs to be even more obese and out of control than they already are while the taxpayer is footing the bill,” said Elizabeth Wright, health and science division director.

Medicare for 41.3 million beneficiaries cost $274 billion last year, according to the Congressional Budget Office.

With 64 percent of the American population overweight or obese, a substantial percentage of Medicare participants probably would qualify, spelling trouble for the program, Ms. Wright said.

Trial lawyers also may use the policy change as another weapon in their arsenal against the food and restaurant industries, Ms. Wright added. Several lawyers have filed lawsuits against the industries trying to blame them for America’s weight problem.

America’s Health Insurance Plans, a Washington trade association for the industry, said its 1,300 members welcomed the policy change.

Many health insurers have been covering treatments such as bariatric surgery for people who are morbidly obese, defined as at least 100 pounds overweight or having a body mass index higher than 40, said Karen Ignagni, president and chief executive officer.

The BMI uses height and weight to determine body fat. However, heavier muscle can skew the figure, making some athletes obese under the index’s classifications.

There has been little focus on alternative diet and exercise remedies or weight-management programs, she said.

The policy “creates more balance in the obesity discussion,” Ms. Ignagni said.

Obesity advocates, who have long lobbied Congress to classify excessive weight as a disease, also approved of Mr. Thompson’s decision.

“The decision by Medicare recognizes that obesity is not simply a cosmetic issue. It is a disease in its own right,” said Richard Atkinson, president of the American Obesity Association.

Sen. Tom Harkin, Iowa Democrat, said the measure was a good first step but noted it did not address the need for preventive health services.

“Everyone talks about the runaway costs of health care. But we are doing precious little to address the root problem: our neglect of prevention and wellness,” Mr. Harkin, who has introduced several bills aimed at reducing obesity rates, said at the hearing.

Chad Clanton, campaign spokesman for Sen. John Kerry of Massachusetts, presumptive Democratic presidential nominee, said the policy seemed to be going in the right direction, but that the campaign would need to see details.

“We view obesity as an important health issue that has to be addressed and support efforts for the Medicare program to do more. We look forward to seeing the details in this plan,” Mr. Clanton said.

The Bush administration has ensured that regulatory policies for Medicare pass cost-benefit analyses, have solid scientific data and improve the public health, a White House spokesman said.

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