In contrast, just 17% of the total cost of hypertension—$4.1 billion—was direct costs related to overweight and obesity. Of the $3.4 billion total cost of gallbladder disease, $3.2 billion was related to overweight and obesity, and of the $21.2 billion total cost of osteoarthritis, the direct cost linked to overweight and obesity was $5.3 billion.
Of the $2.9 billion total cost of breast cancer, $1.1 billion was considered direct cost related to overweight and obesity. For endometrial cancer the direct cost was $310 million of the $933 million total cost, and for colon cancer the direct cost was $1.3 billion of the $3.5 billion total cost.
The WIN researchers also calculated indirect costs of $58.8 billion in 2001, comparable to the economic toll of cigarette smoking. The indirect costs attributed to specific diseases included $15.9 billion for osteoarthritis, $187 million for gallbladder disease, $1.8 billion for breast cancer, $623 million for endometrial cancer, and $2.2 billion for colon cancer.
According to the WIN, the cost of lost productivity related to obesity (BMI greater than 30) among Americans aged seventeen to sixty-four is about $3.9 billion annually. This dollar figure translates into 39.3 million lost work days, 62.7 million physician office visits, 239 million days of restricted activity, and 89.5 million bed-days (days when people remained in bed rather than performing their activities of daily living) related to obesity.
Another study conducted by health economist Roland Sturm and psychiatrist Kenneth Wells at the RAND Corporation, a nonprofit research organization that analyzes challenges facing the public and private sectors, compared effects of obesity, smoking, heavy alcohol consumption, and poverty on chronic health conditions and health expenditures ("The Effects of Obesity, Smoking, and Problem Drinking on Chronic Medical Problems and Health Care Costs," Health Affairs, vol. 21, no. 2, March-April 2002). Sturm and Wells found that obese individuals spent more on both health-care services and medication than daily smokers and heavy drinkers. For example, obese individuals spent about 36% more than the general population on health-care services, compared with a 21% increase for daily smokers and a 14% increase for heavy drinkers. Further, obese people spent 77% more on medications. The only variable with a greater effect on health-care expenditures was aging—and aging trumped obesity only on expenditures for medications. The investigators concluded that obesity generates significantly higher health-care expenditures and affects more individuals than smoking, heavy drinking, or poverty.
Although it is well documented that obese people incur higher health-care costs at a given point in time, until recently, the effects of rising rates of obesity on TABLE 7.2 Rates of discharges and days of care in non-federal short-stay hospitals, according to sex, age, and selected first-listed diagnoses, selected years 1990–2003spending growth had not been quantified. Investigator Kenneth E. Thorpe and his colleagues found that health-care spending was about 36% higher for obese adults under sixty-five, and they sought to estimate the share of spending growth attributable to three obesity related comorbidities—diabetes, hyperlipidemia, and heart disease including hypertension. An analysis of data from the 1987 National Medical Expenditure Survey and the 2001 Medical Expenditure Panel Survey revealed that increases in the proportion of, and spending on, obese people relative to people of normal weight accounted for 27% of the increase in per capita spending between 1987 and 2001. This increase was attributable to spending for diabetes (38%), hyperlipidemia (22%), and heart disease (41%). Increases in obesity prevalence alone accounted for 12% of the growth in health-care spending. The investigators concluded that future cost-containment efforts should address the increasing prevalence of obesity
| TABLE 7.2 | ||||||
|---|---|---|---|---|---|---|
| Rates of discharges and days of care in non-federal short-stay hospitals, according to sex, age, and selected first-listed diagnoses, selected years 1990–2003 | ||||||
| [Data are based on a sample of hospital records] | ||||||
| Sex, age, and first-listed diagnosis | Discharges | Days of care | ||||
| 1990 | 2000 | 2003 | 1990 | 2000 | 2003 | |
| Both sexes | Number per 1,000 population | |||||
| Totala, b | 125.2 | 113.3 | 119.5 | 818.9 | 557.7 | 574.6 |
| Male | ||||||
| All agesa, b | 113.0 | 99.1 | 104.4 | 805.8 | 535.9 | 546.7 |
| Under 18 yearsb | 46.3 | 40.9 | 44.9 | 233.6 | 195.6 | 200.0 |
| Pneumonia | 5.3 | 5.4 | 5.9 | 22.6 | 17.3 | 19.1 |
| Asthma | 3.3 | 3.5 | 2.0 | 9.3 | 7.4 | 4.7 |
| Injuries and poisoning | 6.8 | 5.0 | 5.5 | 30.1 | 21.4 | 21.6 |
| Fracture, all sites | 2.2 | 1.8 | 2.0 | 9.3 | 7.2 | 6.1 |
| 18-44 yearsb | 57.9 | 45.0 | 47.7 | 351.7 | 217.5 | 236.0 |
| HIV infection | 0.3* | 0.6 | 0.5 | 3.0* | 5.4* | 4.3 |
| Alcohol and drugc | 3.7 | 4.0 | 3.6 | 33.1 | 19.1 | 14.9 |
| Serious mental illnessd | 3.4 | 5.3* | 5.8 | 47.1 | 43.6* | 46.2 |
| Diseases of heart | 3.0 | 2.7 | 3.0 | 16.3 | 9.4 | 13.5* |
| Intervertebral disc disorders | 2.6 | 1.5 | 1.2 | 10.7 | 3.2 | 2.9 |
| Injuries and poisoning | 13.1 | 7.3 | 8.4 | 65.7 | 33.2 | 40.8 |
| Fracture, all sites | 4.0 | 2.5 | 3.0 | 22.7 | 12.8 | 15.5 |
| 45-64 yearsb | 140.3 | 112.7 | 120.1 | 943.4 | 570.4 | 605.0 |
| HIV infection | 0.1* | 0.5* | 0.7* | * | * | * |
| Malignant neoplasms | 10.6 | 6.2 | 6.6 | 99.1 | 42.1 | 44.7 |
| Trachea, bronchus, lung | 2.7 | 0.9 | 0.9 | 19.1 | 5.2 | 6.1 |
| Diabetes | 2.9 | 3.7 | 3.1 | 21.2 | 22.5 | 14.8 |
| Alcohol and drugc | 3.5 | 3.5 | 4.2 | 29.7 | 15.8 | 18.7 |
| Serious mental illnessd | 2.5 | 4.0* | 4.4 | 34.8 | 34.6* | 39.9 |
| Diseases of heart | 31.7 | 26.4 | 24.7 | 185.0 | 101.5 | 99.0 |
| Ischemic heart disease | 22.6 | 17.7 | 14.8 | 128.2 | 63.8 | 56.1 |
| Acute myocardial infarction | 7.4 | 5.9 | 4.8 | 55.8 | 27.8 | 25.0 |
| Congestive heart failure | 3.0 | 3.3 | 3.9 | 19.7 | 17.2 | 18.5 |
| Cerebrovascular diseases | 4.1 | 3.8 | 3.8 | 40.7 | 19.8 | 16.6 |
| Pneumonia | 3.5 | 3.4 | 4.1 | 27.4 | 20.5 | 24.9 |
| Injuries and poisoning | 11.6 | 8.8 | 11.0 | 82.6 | 49.8 | 60.9 |
| Fracture, all sites | 3.3 | 2.5 | 3.1 | 24.2 | 16.2 | 18.0 |
| 65-74 yearsb | 287.8 | 264.9 | 276.5 | 2,251.5 | 1,489.7 | 1,465.3 |
| Malignant neoplasms | 27.9 | 17.6 | 19.3 | 277.6 | 121.2 | 124.7 |
| Large intestine and rectum | 3.0 | 3.0 | 2.1 | 34.2 | 27.3 | 17.0 |
| Trachea, bronchus, lung | 6.4 | 2.8 | 3.6 | 55.7 | 19.2 | 21.0 |
| Prostate | 5.1 | 3.7 | 3.9 | 33.1 | 14.0 | 12.7 |
| Diabetes | 4.4 | 4.7 | 5.1 | 39.8 | 29.0 | 27.9 |
| Serious mental illnessd | 2.5 | 3.4* | 2.8 | 43.8 | 39.9 | 28.6 |
| Diseases of heart | 69.4 | 70.6 | 66.3 | 487.2 | 331.9 | 290.0 |
| Ischemic heart disease | 42.0 | 39.7 | 35.2 | 285.2 | 171.2 | 147.4 |
| Acute myocardial infarction | 14.0 | 12.5 | 12.5 | 122.4 | 66.5 | 66.9 |
| Congestive heart failure | 11.4 | 13.4 | 13.5 | 90.2 | 76.8 | 65.6 |
| Cerebrovascular diseases | 13.8 | 13.2 | 13.4 | 114.8 | 59.0 | 57.8 |
| Pneumonia | 11.4 | 12.8 | 12.9 | 107.8 | 82.0 | 77.2 |
| Hyperplasia of prostate | 14.4 | 5.4 | 3.8 | 65.0 | 15.0 | 10.5 |
| Osteoarthritis | 5.0 | 9.6 | 8.7 | 44.9 | 46.7 | 34.7 |
| Injuries and poisoning | 17.6 | 17.9 | 19.2 | 139.0 | 105.7 | 105.6 |
| Fracture, all sites | 4.5 | 4.7 | 4.6 | 45.9 | 29.9 | 27.5 |
| Fracture of neck of femur (hip) | 1.5 | 2.0* | 1.5* | 18.1* | 15.9* | 10.4* |
TABLE 7.2 Rates of discharges and days of care in non-federal short-stay hospitals, according to sex, age, and selected first-listed diagnoses, selected years 1990–2003 [CONTINUED]
and the institution of effective approaches to weight loss for people who are obese (Kenneth E. Thorpe et al., "The Impact of Obesity on Rising Medical Spending," Health Affairs, October 20, 2004).
| TABLE 7.2 | ||||||
|---|---|---|---|---|---|---|
| Rates of discharges and days of care in non-federal short-stay hospitals, according to sex, age, and selected first-listed diagnoses, selected years 1990–2003 [CONTINUED] | ||||||
| [Data are based on a sample of hospital records] | ||||||
| Sex, age, and first-listed diagnosis | Discharges | Days of care | ||||
| 1990 | 2000 | 2003 | 1990 | 2000 | 2003 | |
| Number per 1,000 population | ||||||
| 75 years and overb | 478.5 | 467.4 | 483.1 | 4,231.6 | 2,888.0 | 2,844.9 |
| Malignant neoplasms | 41.0 | 21.9 | 24.1 | 408.3 | 165.2 | 166.8 |
| Large intestine and rectum | 5.4 | 4.2 | 4.0 | 80.7 | 44.1 | 36.9 |
| Trachea, bronchus, lung | 5.4 | 3.0 | 4.1 | 53.4 | 18.3 | 29.3 |
| Prostate | 9.7 | 3.2 | 2.3 | 65.6 | 19.4* | 10.4* |
| Diabetes | 4.6 | 6.5 | 6.6 | 51.2 | 43.2 | 36.5* |
| Serious mental illnessd | 2.6* | 2.9 | 2.5 | 40.5* | 32.6* | 25.2* |
| Diseases of heart | 106.2 | 113.3 | 110.3 | 855.7 | 600.9 | 560.2 |
| Ischemic heart disease | 49.1 | 53.0 | 47.2 | 398.1 | 276.1 | 238.8 |
| Acute myocardial infarction | 23.1 | 23.0 | 21.6 | 227.5 | 136.5 | 142.6 |
| Congestive heart failure | 31.0 | 30.5 | 31.1 | 242.3 | 175.4 | 170.6 |
| Cerebrovascular diseases | 30.2 | 30.2 | 29.1 | 298.3 | 171.2 | 142.2 |
| Pneumonia | 38.6 | 37.2 | 39.7 | 393.6 | 233.3 | 245.2 |
| Hyperplasia of prostate | 17.9 | 6.8 | 5.4 | 109.2 | 21.6 | 17.0 |
| Osteoarthritis | 5.8 | 6.2 | 9.7 | 60.7 | 28.7 | 42.3 |
| Injuries and poisoning | 31.2 | 33.6 | 34.6 | 341.3 | 257.7 | 226.1 |
| Fracture, all sites | 13.7 | 14.4 | 15.3 | 145.1 | 119.2* | 108.0 |
| Fracture of neck of femur (hip) | 8.5 | 8.4 | 9.7 | 97.8 | 63.3 | 67.2 |
| Female | ||||||
| All agesa, b | 139.0 | 127.7 | 135.1 | 840.5 | 581.0 | 605.2 |
| Under 18 yearsb | 46.4 | 39.6 | 42.2 | 218.7 | 161.5 | 190.9 |
| Pneumonia | 4.0 | 4.8 | 4.5 | 17.4 | 17.2 | 13.9 |
| Asthma | 2.2 | 2.4 | 1.3 | 6.8 | 5.5 | 3.1* |
| Injuries and poisoning | 4.3 | 3.1 | 3.6 | 16.7 | 12.0* | 15.4* |
| Fracture, all sites | 1.3 | 0.9 | 1.1 | 6.4 | 2.3 | 3.6 |
| 18-44 years | 146.8 | 124.8 | 135.2 | 582.0 | 401.1 | 444.2 |
| HIV infection | * | 0.3 | 0.3 | * | 2.1* | 2.5 |
| Delivery | 69.9 | 64.5 | 69.5 | 195.0 | 160.2 | 179.6 |
| Alcohol and drugc | 1.6 | 2.1* | 1.9 | 14.1 | 10.8* | 9.5* |
| Serious mental illnessd | 3.7 | 5.4* | 6.0 | 54.3 | 41.1* | 48.2 |
| Diseases of heart | 1.3 | 1.7 | 1.8 | 7.2 | 6.3 | 7.5 |
| Intervertebral disc disorders | 1.5 | 1.0 | 1.1 | 7.3 | 2.4 | 2.6 |
| Injuries and poisoning | 6.7 | 4.3 | 4.8 | 36.6 | 18.1 | 18.9 |
| Fracture, all sites | 1.6 | 1.0 | 1.0 | 10.7 | 4.5 | 4.8 |
| 45-64 yearsb | 131.0 | 110.2 | 116.5 | 886.5 | 533.6 | 560.9 |
| HIV infection | * | * | * | * | * | * |
| Malignant neoplasms | 12.7 | 6.1 | 6.4 | 107.4 | 34.7 | 37.9 |
| Trachea, bronchus, lung | 1.7 | 0.5 | 0.8 | 14.8 | 3.4 | 5.3 |
| Breast | 2.8 | 1.3 | 1.0 | 12.1 | 2.6 | 2.5 |
| Diabetes | 2.9 | 2.9 | 2.8 | 25.8 | 15.0 | 15.3 |
| Alcohol and drugc | 1.0 | 1.5 | 1.6 | 8.0 | 7.1* | 8.2* |
| Serious mental illnessd | 4.0 | 4.6 | 5.4 | 60.5 | 42.7 | 48.1 |
| Diseases of heart | 16.6 | 14.6 | 14.1 | 101.1 | 59.5 | 59.7 |
| Ischemic heart disease | 9.9 | 7.8 | 6.9 | 57.4 | 29.5 | 25.0 |
| Acute myocardial infarction | 2.8 | 2.0 | 1.9 | 21.6 | 10.0 | 8.2 |
| Congestive heart failure | 2.1 | 2.9 | 3.1 | 15.8 | 13.6 | 14.5 |
| Cerebrovascular diseases | 3.0 | 3.5 | 3.0 | 32.1 | 19.5 | 15.3 |
| Pneumonia | 3.4 | 3.6 | 3.9 | 26.5 | 20.8 | 21.3 |
| Injuries and poisoning | 9.4 | 7.7 | 8.8 | 63.3 | 41.2 | 48.8 |
| Fracture, all sites | 3.1 | 2.7 | 2.0 | 25.0 | 13.3 | 9.5 |
Hospital Costs of Childhood and Adolescent Obesity.
Researchers Guijing Wang and William H. Dietz of the CDC examined trends in obesity-linked diseases among children and adolescents and their related economic costs. In "Economic Burden of Obesity in Youths Aged Six to Seventeen Years: 1979–1999" (Pediatrics, vol. 109, no. 5, May 2002), the researchers reported the results of an analysis and comparison of data from the 1979–81 and 1997–99 National Hospital Discharge Surveys conducted by the National Center for Health Statistics. When the researchers adjusted hospital costs to reflect 2001 dollars, they found that hospital costs linked to childhood obesity and three specific obesity-related
TABLE 7.2 Rates of discharges and days of care in non-federal short-stay hospitals, according to sex, age, and selected first-listed diagnoses, selected years 1990–2003 [CONTINUED]
illness—diabetes, sleep apnea, and gallbladder disease—had more than tripled since 1981, from $35 million to $127 million per year.
| TABLE 7.2 | ||||||
|---|---|---|---|---|---|---|
| Rates of discharges and days of care in non-federal short-stay hospitals, according to sex, age, and selected first-listed diagnoses, selected years 1990–2003 [CONTINUED] | ||||||
| [Data are based on a sample of hospital records] | ||||||
| Sex, age, and first-listed diagnosis | Discharges | Days of care | ||||
| 1990 | 2000 | 2003 | 1990 | 2000 | 2003 | |
| *Estimates are considered unreliable. | ||||||
| aEstimates are age adjusted to the year 2000 standard population using six age groups: under 18 years, 18-44 years, 45-54 years, 55-64 years, 65-74 years, and 75 years and over. | ||||||
| bIncludes discharges with first-listed diagnoses not shown in table. | ||||||
| cIncludes abuse, dependence, and withdrawal. These estimates are for non-federal short-stay hospitals and do not include alcohol and drug discharges from other types of facilities or programs such as the Department of Veterans Affairs or day treatment programs. | ||||||
| dThese estimates are for non-federal short-stay hospitals and do not include serious mental illness discharges from other types of facilities or programs such as the Department of Veterans Affairs or long-term hospitals. | ||||||
| Notes: Excludes newborn infants. Diagnostic categories are based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Rates are based on the civilian population as of July 1. Starting with Health, United States, 2003, rates for 2000 and beyond are based on the 2000 census. Rates for 1990–99 use population estimates based on the 1990 census adjusted for net underenumeration using the 1990 National Population Adjustment Matrix from the U.S. Bureau of the Census. Rates for 1990–99 are not strictly comparable with rates for 2000 and beyond because population estimates for 1990–99 have not been revised to reflect Census 2000. | ||||||
| SOURCE: "Table 98. Rates of Discharges and Days of Care in Non-Federal Short-Stay Hospitals, According to Sex, Age, and Selected First-Listed Diagnoses: United States, Selected Years 1990–2003," in Health, United States, 2005, Centers for Disease Control and Prevention, National Center for Health Statistics, December 8, 2005, http://www.cdc.gov/nchs/data/hus/hus05.pdf#chartbookontrendsinthe (accessed January 20, 2006) | ||||||
| Number per 1,000 population | ||||||
| 65-74 yearsb | 241.1 | 246.1 | 255.5 | 1,959.3 | 1,397.1 | 1,398.4 |
| Malignant neoplasms | 20.9 | 14.1 | 14.5 | 189.8 | 101.0 | 98.5 |
| Large intestine and rectum | 2.4 | 1.7 | 2.0 | 34.9 | 15.2 | 17.1 |
| Trachea, bronchus, lung | 2.6 | 2.4 | 2.5 | 26.9 | 17.5* | 16.8 |
| Breast | 3.9 | 2.8 | 2.2 | 17.6 | * | 4.3* |
| Diabetes | 5.8 | 4.6 | 5.1 | 46.8 | 26.1 | 26.8 |
| Serious mental illnessd | 3.9 | 4.0 | 4.4 | 62.8 | 46.3 | 44.1 |
| Diseases of heart | 45.1 | 52.1 | 48.0 | 316.9 | 256.0 | 229.6 |
| Ischemic heart disease | 24.4 | 23.3 | 20.5 | 153.8 | 113.9 | 86.8 |
| Acute myocardial infarction | 7.5 | 8.0 | 7.6 | 58.1 | 52.8 | 40.6 |
| Congestive heart failure | 9.2 | 12.7 | 11.6 | 81.8 | 68.4 | 61.8 |
| Cerebrovascular diseases | 11.3 | 12.3 | 11.1 | 96.0 | 59.4 | 58.4 |
| Pneumonia | 8.7 | 11.7 | 11.8 | 81.8 | 73.5 | 65.6 |
| Osteoarthritis | 6.9 | 9.3 | 13.2 | 68.9 | 43.6 | 54.7 |
| Injuries and poisoning | 17.8 | 18.3 | 18.5 | 166.2 | 109.9 | 103.2 |
| Fracture, all sites | 8.4 | 7.7 | 7.3 | 97.3 | 43.8 | 39.8 |
| Fracture of neck of femur (hip) | 3.6 | 3.2 | 2.8 | 59.6* | 21.1 | 16.8 |
| 75 years and overb | 409.6 | 458.8 | 470.5 | 3,887.1 | 2,830.8 | 2,734.8 |
| Malignant neoplasms | 22.1 | 17.6 | 15.9 | 257.3 | 125.7 | 124.5 |
| Large intestine and rectum | 4.6 | 3.4 | 2.8 | 69.8 | 28.4 | 26.8 |
| Trachea, bronchus, lung | 2.1 | 1.9 | 2.0 | 20.6 | 14.0 | 16.2* |
| Breast | 3.9 | 2.5 | 1.4 | 22.0 | 8.9* | 4.4* |
| Diabetes | 4.6 | 6.3 | 6.2 | 55.3 | 34.0 | 28.6 |
| Serious mental illnessd | 4.2 | 4.7 | 3.3 | 78.4 | 49.2 | 37.2 |
| Diseases of heart | 84.6 | 99.1 | 97.2 | 672.8 | 523.4 | 480.1 |
| Ischemic heart disease | 33.7 | 35.5 | 32.1 | 253.2 | 185.5 | 150.8 |
| Acute myocardial infarction | 13.1 | 16.5 | 15.8 | 125.9 | 110.7 | 95.1 |
| Congestive heart failure | 28.0 | 32.2 | 29.6 | 236.6 | 181.7 | 159.4 |
| Cerebrovascular diseases | 29.6 | 27.6 | 24.5 | 302.0 | 156.8 | 138.3 |
| Pneumonia | 23.9 | 30.5 | 29.7 | 260.1 | 209.7 | 189.9 |
| Osteoarthritis | 5.3 | 8.7 | 10.6 | 54.1 | 40.4 | 45.8 |
| Injuries and poisoning | 46.3 | 44.7 | 46.2 | 489.2 | 275.4 | 271.0 |
| Fracture, all sites | 31.5 | 30.0 | 29.4 | 352.7 | 190.0 | 173.5 |
| Fracture of neck of femur (hip) | 18.8 | 17.9 | 15.5 | 236.3 | 125.3 | 98.6 |
Days spent in the hospital for obesity-related disease more than doubled, from 152,000 during 1979–81 to 310,000 days during 1997–99. The average length of hospital stays increased by about a third, from 5.3 to seven days. The researchers observed that this increase in average length of stay occurred during a time when U.S. hospital stays overall were shortening, and asserted that longer lengths of stay for children with obesity-related medical problems underscored the severity of these problems.
The researchers concluded that the increase in the percentage of discharges with obesity-related diseases was most likely a reflection of the medical consequences of the obesity epidemic. They wrote, "Although the numbers of percentage are small, the increases are substantial, especially for obesity (197% increase), sleep apnea (436%), and gallbladder disease (228%). These data may suggest that the increasing prevalence of obesity in children and adolescents has led to increased hospital stays related to obesity-associated diseases. The increasing proportion of hospital discharges with obesity-associated diseases in the last twenty years may also reflect the impact of increasing severity of obesity."
Insurance Coverage for Obesity Treatment
Although the Medicare and Medicaid programs spend billions on obesity-related illnesses, neither entitlement program covers treatment for obesity itself. Medicaid does not cover obesity treatment, and under Medicare, hospital and physician services for obesity are generally excluded. Historically, Medicare has covered treatment when obesity results from a disease such as hypothyroidism or Cushing's disease and when weight loss is medically necessary to treat a disease such as diabetes, hypertension, or heart disease. It also provides coverage for surgical treatment of obesity when it is medically appropriate and the surgery is to correct an illness that caused the obesity or was aggravated by the obesity.
Until 2004 Medicare justified excluding coverage for obesity treatment by asserting that obesity is not a disease; however, in July 2004 the Centers for Medicare & Medicaid Services, which administers Medicare, eliminated language from its policy (that "obesity itself cannot be considered an illness") that had been used to deny coverage for weight-loss treatment. While the decision stopped short of designating obesity a disease and does not specifically grant coverage for weight-loss treatment, it enables individuals, physicians, and companies to apply to Medicare for reimbursement for a variety of weight-loss therapies. Since private insurance companies often use Medicare as a model for their coverage and benefits, some health-care industry observers believe the Medicare decision will pressure other payers to cover weight-loss treatments.
In view of the high prevalence of obesity among the populations covered by Medicaid—the poor and minori-ties—and the significant Medicaid expenditures for obesity-related illnesses, many health-care industry observers believe it is short-sighted that twenty-nine states specifically exclude coverage of antiobesity products in state Medicaid programs. Just nine states—Alaska, California, Kentucky, Montana, North Carolina, Oregon, Rhode Island, Washington, and Wisconsin—cover antiobesity pharmaceuticals through Medicaid. Arizona covers antiobesity pharmaceuticals through a specific managed health-care plan. Some health-care analysts, and advocacy groups including the AOA, contend that it is difficult to reconcile this limited coverage of obesity in light of Medicaid coverage for inpatient and outpatient alcohol detoxification and rehabilitation; chemical dependency treatment and drug rehabilitation; and services for sexual impotence.
In January 2005 Edolphus Towns (D-NY) introduced a bill in the U.S. House of Representatives that would amend title XIX of the Social Security Act to require states that provide Medicaid prescription drug coverage to cover drugs medically necessary to treat obesity. However, this act (H.R. 286, known as the "Medicaid Obesity Treatment Act of 2005") was referred to the Subcommittee on Health in February 2005 and by the end of 2005 had not made it out of committee.
According to the AOA, many health insurance plans do not provide reimbursement for weight-loss treatment. Further, few private insurance indemnity plans or managed-care organizations (health maintenance organizations and preferred-provider organizations are examples of managed-care plans) appear to cover the costs of obesity treatment independent of whether the service is a medically supervised weight-loss program, surgery, or a prescription drug. The AOA notes that most employer-funded health insurance plans do not pay for obesity treatment or services, including medications, diet supplements, appetite control programs, gastric bypasses, or other surgeries. During 2005 at least five states—Georgia, Hawaii, Maryland, Montana, and Virginia—considered legislation that would require health insurance coverage for weight-loss programs.
The Pharmacy Benefit Management Institute, Inc. (PBMI), an independent organization that is not affiliated with any employee benefits program or pharmaceutical manufacturer, periodically surveys employers to determine the extent, cost, and coverage of their pharmacy benefits. The Institute analyzes survey data and trends in a national research report entitled Benefit Design Survey Report. The 2004 survey queried 375 companies that provide coverage to nearly twelve million beneficiaries. The PBMI study found that antiobesity drugs, including appetite suppressants, were excluded from coverage by more than 80% of employers.
Although reluctance to cover antiobesity drugs is driven by concern about cost—many payers may find that the rising prevalence of obesity and its comorbidities require higher prescription drug costs than drug treatment of obesity itself. For example, research conducted by Medco Health Solutions, a national prescription benefit management company, found that Americans with metabolic syndrome account for $4 of every $10 spent on prescription drugs for adults. (Metabolic syndrome is the name given to conditions that often occur together—obesity, diabetes, high blood pressure, and high triglycerides that can lead to cardiovascular disease.) Drug treatment of metabolic syndrome skyrocketed 36% between 2002 and 2004 and prescription costs for adults with metabolic syndrome averaged $4,116 in 2004—4.2 times the average (Linda Johnson, "Study: Metabolic Syndrome Brings Big Costs," Associated Press, May 7, 2005).
SHOULD OVERWEIGHT PEOPLE PAY MORE FOR HEALTH INSURANCE COVERAGE?
Since overweight and obese people incur higher medical costs, should they be required to pay higher premiums for health insurance? During 2003 at least one Maryland legislator, Joan F. Stern, suggested this highly controversial move. In a July 11, 2003, interview with Steven Dennis, "Shape Up or Shell Out?" in The Gazette, Stern, who had lost thirty pounds at the time of her proposal, said that higher premiums for the overweight and discounts for people of healthy weights would improve health, help pay for the cost of medical treatment for obesity, and would reduce health insurance costs. She explained that "You can be as fat as you want, but when you become a burden on the health-care system, when you start going to the emergency room, when you start having to take insulin and these other drugs, the insurance premiums of everyone else go up and some people won't be able to afford it because of folks who abuse the system—and it really is abusing the system." Her plan would not penalize people whose obesity was caused by a medical problem such as Cushing's disease and would prevent insurance companies from denying coverage to obese people.
In his article, reporter Dennis observed that after an earlier story about her proposal appeared in The Gazette, Stern softened her position because she feared that she would be viewed as attacking overweight people. She shifted her focus to insurance coverage for obesity treatments and insurance incentives tied to reducing obesity. In addition she advocated requiring daily physical education in schools, improving school nutrition standards, and revamping school menus.
While Stern may have reconsidered her position about higher health insurance premiums for obese people, George Washington University Law School professor John F. Banzhaf III is a staunch advocate of such a policy. He maintains that the current practice of charging all insurance subscribers the same rates unfairly forces normal-weight people to subsidize treatment for obesity. Banzhaf asserts that higher insurance premiums would give obese people another incentive to lose weight and observes that this policy would be consistent with others such as requiring smokers to pay more for life insurance, and drivers who have car accidents to pay higher automobile insurance rates.
In June 2004 Banzhaf petitioned the U.S. Department of Health and Human Services to reverse its 1987 decision prohibiting health insurance companies from charging different health insurance premiums for people who are obese. On September 28, 2004, Banzhaf received a letter from the Centers for Medicare and Medicaid Services (CMS) in response to his petition. The CMS stated that it could theoretically allow federally qualified HMOs to use obesity as a factor in predicting use of health services but observed that no federally approved HMO had asked to do so. According to the CMS, even if it changed its position on obesity under Title XIII, community rating provisions would have very limited effect in light of subsequently enacted provisions contained in the Health Insurance Portability and Accountability Act of 1996 (HIPPA) that prohibit discrimination against individuals based on health status. The CMS also asserted that federal law does not prevent insurers from offering premium discounts or rebates in return for adherence to programs designed to improve health; however, federal regulations limit this exception to incentives provided to wellness programs that meet specific criteria. The discount cannot exceed 10% to 20%; it must be designed to promote good health and not be a ploy to raise rates for certain individuals; it must be available to all similarly situated individuals; individuals must be offered an alternative way to qualify for the incentive; and plan materials must describe the availability of the alternatives. Although Banzhaf's Web site (http://banzhaf.net/obesitylinks) trumpeted the CMS response as a far-reaching change in legislative policy, terming it "Govt. Rules Health Insurance Companies Can Charge the Obese More to Help Encourage Them to Lose Weight and to Pay More of Medical Costs of Obesity," CMS did not in fact, change its policy.
Critics of higher premiums for overweight and obese people counter that since smokers and people who consume alcohol excessively do not pay higher health insurance premiums under most plans, obese people should not be asked to pay higher premiums. A 2005 Gallup Poll found that two-thirds of Americans believed that charging obese people higher insurance premiums was unjustified (Personal Weight Situation, August 2005). Executive director of the AOA Morgan Downey believes that economic incentives would not be effective inducements for weight loss, and observes that the entire premise of insurance is to share risk across a population that varies in terms of health and illness. Other health-care industry observers contend that some health insurance companies already discriminate against obese people by denying them coverage or imposing higher deductibles (the fixed dollar amount subscribers must pay before their health benefits begin). Finally, opponents observe that overweight people might be forced to drop their health insurance coverage altogether should it become too expensive, and that more obese people might rely on publicly funded programs, ultimately shifting obesity-related medical costs to taxpayers.
Obese People Pay More for Health Care
Researchers at the Institute for the Study of Health at the University of Cincinnati Academic Health Center found that adults with clinically severe obesity (also known as morbid obesity, defined as 100 pounds or more over ideal body weight or BMI ≥40) had health-care costs that were nearly twice those of their normal weight peers (David Arterburn et al., "Impact of Morbid Obesity on Medical Expenditures in Adults," International Journal of Obesity, vol. 29, no. 3, March 1, 2005). The researchers analyzed the records of 16,262 adults from the 2000 Medical Expenditure Panel Survey. Per capita healthcare expenditures were calculated for BMI categories, based on self-reported height and weight, and adjusted for age, gender, race, income, education level, type of health insurance, marital status, and smoking status.
The researchers found that in 2000, medical expenditures for people with clinically severe obesity were 81% higher than expenditures for normal-weight adults, 65% more than for overweight adults, and 47% more than those of obese adults. The excess costs resulted from greater spending on physician office visits, outpatient hospital care, inpatient hospital care, and prescription drugs. The investigators estimated that $56 billion in U.S. health-care expenditures in 2000 were linked to excess body weight—up 12% from 1998.
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