Open enrollment for the state health insurance exchanges created under the Affordable Care Act (ACA) begins in October, but many Americans, including health care professionals, remain uncertain and confused about the status of one of the most sweeping and important pieces of legislation to ever hit health care.
According to a Kaiser Family Foundation poll conducted in April, more than 40 percent of Americans do not know that the ACA is law, including 12 percent who believe it has been repealed by Congress and 7 percent who believe it has been overturned by the U.S. Supreme Court. Nearly half of Americans report they do not have enough information to understand how it will impact their own family. Most of those who do have some awareness of the law say they received information primarily from friends, family and the media. Only 10 percent say a health insurer, doctor, employer or a non-profit organization was their source of information.
How much do you know about the Affordable Care Act and what does it mean for obesity treatments including metabolic and bariatric surgery?
John Morton, MD
According to John Morton, MD, ASMBS Secretary-Treasurer and former Access to Care Committee Chair, the answer depends on where you live. He says though obesity is a national epidemic that knows no boundaries, obesity treatment under ACA is largely being handled at the state level.
“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.”
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, DC states currently have no plans to include it.
One of those states where obesity treatment for the newly insured may be excluded is Pennsylvania, where ASMBS State Chapter President, Michael Bono, MD, director of Northeast Bariatric Center in Hazelton, PA, remains “cautiously optimistic” despite the challenges that lie ahead.
“It's like playing chess,” said Dr. Bono. “When faced with a challenge, you have to counter with education, advocacy and evidence to support your position,” said Dr. Bono. “We believe the evidence is on our side.”
In April, members of the ASMBS Pennsylvania state chapter, which is now 40 strong, went to Capitol Hill, where they met with legislative staff from seven Congressional offices. They returned with a commitment from U.S. Representative Lou Barletta to spearhead a letter from members of Congress to U.S. Health and Human Services (HHS) Secretary Kathleen Sebelius calling for the agency to define the management of obesity and metabolic disorders as part of “chronic disease management.” Chronic disease management is one of 10 categories which must be included in each state's EHB.
This complements efforts by ASMBS and other groups including The Obesity Society, American Association of Clinical Endocrinologists and Academy of Nutrition and Dietetics who in a letter last December urged the secretary to also define obesity as a chronic disease, similar to diabetes, heart disease and cancer.
In April, ASMBS officials and members of other obesity organizations met with HHS to follow up on that letter and secure clear federal guidance regarding coverage of evidence-based obesity treatment services as a medically necessary essential health benefit. No guidance has been issued as of yet.
“The clock is ticking and we have to make the noise now and continue to make noise to improve patient access,” said Christopher Gallagher, Director of the ASMBS Washington Office, who helps the ASMBS with its lobbying efforts. “It doesn't end in 2014 when the state health care exchanges get implemented. The defined Essential Health Benefits are subject to change again in two years and we want obesity treatment covered by every state, not just a percentage.”
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.
“We believe that with more focus on obesity, there will be better access to evidence-based solutions like surgery, now and tomorrow,” said Dr. Morton.”Prevention and screening alone cannot solve the obesity crisis, nor can surgery or other stand-alone interventions. The future solution will be a continuum of care, complementary to the many challenges of obesity. The sooner we marry prevention and intervention, the sooner we will be able to save more lives and turn back the twin epidemic of obesity and diabetes, an epidemic that is spiraling out of control.”