Rationing Healthcare for the Obese under Obamacare

Preventive Services Mandated by Healthcare Reform

The federal healthcare reform law, known as the Patient Protection and Affordable Care Act (PPACA), mandates 100 percent coverage—pre-deductible—for many preventive services. Beginning October 1, 2010, upon renewal, employer health plans will be required to cover these designated preventive health services, as outlined by the federal Interim Final Regulations.

To get HITECH incentive money, medical providers are required to use their electronic health record systems to report clinical quality measures. That requirement could prove as challenging to meet as all the others put together. For HITECH Stage 1, physicians must report six measures. Three must be core measures (adult blood pressure screening, weight screening, and tobacco use assessment/intervention), or alternate core measures (childhood immunization status, child and adolescent weight screening and counseling, and flu vaccinations for patients 50 or older) depending on which correlate best with their patient populations.

A great deal has been written about health care reform during the past year but little attention has been paid to how reform might affect the obesity epidemic. The legislation incorporates recommendations of the U.S. Preventive Services Task Force (USPSTF) meaning that these recommendations become covered services. The USPSTF has two obesity specific recommendations at level B: one for screening for obesity and the second for intensive behavioral counseling. The intensive behavioral counseling could open the door for extensive new services.

If you have obesity and have employer-paid health insurance, you may be paying more – potentially a lot more-for it. While the new law will ban discrimination on the basis of health status, an exception exists whereby persons in an employee wellness program can be charged up to 50% of the value of their health insurance premium if they do not meet specific health criteria, such as weight.

Intensive behavioral counseling for obesity will become more available. Whether insurers will have to provide bariatric surgery or drugs for treating obesity will be decided by a Health Benefits Advisory Board which will make recommendations to the Secretary of Health and Human Services.

The tax deduction for medical expenses will change. Currently, individuals can deduct unreimbursed medical expenses (including physician recommended weight loss costs) to the extent they exceed 7.5% of adjusted gross income. The threshold will rise to 10%. This potentially hurts individuals with multiple chronic conditions and/or high, unreimbursed medical costs.

Medicare beneficiaries would receive a comprehensive health risk assessment and a personalized prevention plan. Incentives would be provided to Medicare beneficiaries to compete behavioral modification programs. The ban for drugs to treat obesity under Part D continues in effect.

Under health care reform, the Medicaid program will go through its largest expansion since its inception. If cost-sharing is removed for covered recommendations of the US Preventive Services Task Force (see above), state Medicaid programs will have their federal matching rates increased. The Secretary of Health and Human Services (HHS) is also instructed to develop preventive and obesity-related services for Medicaid enrollees, including obesity screening and counseling for children and adults. Each state is directed to develop a public awareness campaign to educate Medicaid enrollees regarding the “availability and coverage of such services with the goal of reducing incidences of obesity.”

HHS will develop incentives to encourage behavioral change in Medicaid enrollees.

A new state option will be developed for Medicaid, allowing enrollees with multiple chronic conditions to select a medical home. For the increasing numbers of children and adolescents with obesity, their related conditions, like type 2 diabetes and hypertension, will now be covered under Medicaid. In addition to the coverage components, the law provides funding for a childhood obesity demonstration project.

The healthcare bill establishes a National Prevention, Health Promotion and Public Health Council to coordinate federal prevention, wellness and public health activities and develop a national strategy to improve the nation’s health. The strategy is due one year after the enactment. A Prevention and Wellness Trust is authorized to carry out the national strategy.

A grant program is developed for 5 years to support the delivery of evidence-based and community based prevention and wellness service aimed at reducing chronic disease rates. Grantees must report changes in weight, nutrition, physical activity.

The Secretary of HHS is mandated to develop, within one month of passage, an education and outreach campaign regarding preventive health services. The campaign must address proper nutrition, regular exercise and obesity reduction. It is mandated that the Secretary develop a website for health care providers and consumers to provide science-based information on guidelines for nutrition, exercise, obesity reduction and specific chronic disease prevention. Another website is to be developed with a “personalized prevention plan tool. This would include determining individual disease risk, based in part on Body Mass Index.

Restaurants which are part of a chain of 20 or more locations doing business under the same name must disclose for ‘standard menu items’ the nutrient content including calories in the item with the suggested daily caloric intake on the menu as well as a drive-through menu board. Self-service items must also display the calorie information. Restaurants and others, such as vending machine operators, may voluntary register to be part of the program. Regulations must be issued within a year of enactment.

The Secretary of Labor is authorized to set up a grant program for employer wellness programs. Behavioral change is encouraged which provides for altering employee healthy lifestyles through counseling, seminars, on-line programs or self-help materials. Obesity is specifically listed as a focus. Participation cannot be mandated or conditioned on obtaining a health insurance premium discount, rebate or other financial reward.

Key points of federally mandated preventive services from birth to age 18:

• Coverage must follow ongoing recommendations by the U.S. Preventive Services Task Force, Advisory Committee of Immunization Practices of the Centers for Disease Control and the Health Resources and Services Administration.


• Full coverage for well-baby exams — birth to 30 months: weight, length, and head circumference.


• Full coverage for annual well-child exams — ages 3 to 18 years: Height, weight and body mass index (BMI) percentile-for-age; discussions on health and wellness issues (nutrition, healthy weight, injury prevention, avoidance of tobacco, alcohol and drugs, sexual behavior, dental health, mental health and second hand smoke).


• Federally mandated preventive services for adults 19 and older: Height, weight, and body mass index (BMI) screening, Counseling on health and wellness issues (nutrition, exercise, injury prevention, misuse of drugs and alcohol, tobacco cessation, second hand smoke, sexual behavior, dental health, and mental health).

Flashback: Smokers, Obese Individuals Could Face Higher Premiums

September 30, 2009

POLITICO - Despite opposition from more than 50 health groups, the Finance Committee approved an amendment Wednesday allowing employers to increase premiums by up to 50 percent for people who engage in unhealthy behaviors.

That means smokers, obese individuals and others may face higher premiums if they do not participate in wellness programs.

Sen. John Ensign (R-Nev.) and Sen. Tom Carper (D-Del.) described their amendment as a common-sense measure aimed at providing a financial incentive for people to change unhealthy behaviors.

But opponents – which included four Democratic senators and groups such as the American Cancer Society, American Heart Association and the AFL-CIO — said it allows insurers and self-insured businesses to continue to base coverage decisions on preexisting conditions, which the underlying bill would prohibit.

“While we appreciate the amendments’ intent to encourage healthy behaviors, we believe that allowing employers to vary premiums by up to 50 percent of the total cost of employee coverage could lead to discriminatory practices and make health coverage unaffordable for those who need it the most,” the groups signed in a joint letter.

Currently, employers can vary premiums by 20 percent, the letter stated.

Sen. Mike Enzi (R-Wyo.) said the Health, Education, Labor and Pensions Committee adopted a similar bipartisan amendment by unanimous consent during its markup in July, but the language has since “unilaterally changed.”

“My colleagues were never consulted and the Democratic majority staff removed it,” Enzi said. “We had to discover it on our own. I hope it will get into this bill so it will be considered in a merged bill.”

Read More...