Rethinking Weight
Hey, maybe it's not a weakness. Just maybe. . .it's a disease
Frauds. The biggest dilemma overweight people face is the world of largely mediocre, misleading, useless, or downright dangerous devices, diet programs, supplements, and drugs promoted to reduce fat. "The treatment of obesity is littered with a history of abuses," says NAASO's Aronne. "Every infomercial out there about weight is damaging people because it's giving them an unrealistic view of what can be done." Most university- and hospital-based weight-loss programs produce a 10 percent loss of body weight in six months. This is more than enough to reduce the incidence of Type II diabetes by 58 percent and lower blood pressure in borderline hypertensives. But it is not enough to make a fat person as thin as a Hollywood celebrity. Coverage of obesity by health insurers might bring science and sanity to the chaos of weight loss, where, as Aronne puts it, "ethical treatments are competing in an unethical marketplace."
But clinicians acknowledge that weight-loss successes are modest. "To be frank, a lot of the treatment has not been very effective," says Pi-Sunyer. He points out that there are currently two drugs approved for long-term treatment of obesity, sibutramine and orlistat. Their effect is modest, and their cost is high, about $100 a month. "So for people to pay that amount, they would like to see more impressive results." Two drugs approved for treating epilepsy, topiramate and zonisamide, are being tested to treat obesity, but the jury is still out on them. "So that's an out for the insurers," says Pi-Sunyer. They can say, `Unless you have a treatment that takes weight off and keeps it off, then why pay for it?' It would be a much stronger argument if we had a more proven treatment."
What's standing in the way? Basically funding for research. The American Obesity Association reports that NIH funding for research on obesity is less than one sixth that spent on AIDS. "Given the nature of the problem and the side effects," says Pi-Sunyer, "we're spending a pittance."
The health insurance industry argues that obesity treatments can't be covered because there is no evidence of effectiveness. Critics counter that the same argument could apply to a lot of complicated diseases. "We don't have a good way of treating Alzheimer's disease," says GWU's Frank, "and we don't have a particularly good way of treating AIDS either. We have a health insurance system based on illness, not treatment effectiveness. Why should obesity be the one disease that's subjected to this cost-effectiveness standard?"
About half of the $75 billion yearly price tag for obesity is covered by taxpayers in Medicare and Medicaid funds. These government health plans are debating right now whether the plans should cover obesity treatment. Currently, only in cases of severe obesity will government and some private insurers reimburse doctors for surgery to reduce girth.
But not always. Samantha Moore, a 26-year-old Maine woman who weighs nearly 400 pounds, was recently turned down a third time for gastric bypass surgery. Even though she has been dieting all her life, her insurer denied surgery because she has not made enough "medically supervised" attempts at weight loss. Does the insurer pay for medically supervised weight loss? "No," says Moore. "It's shocking to me that the insurance company keeps saying, essentially, `You're not sick enough to get this surgery.' I think they're putting off a decision because if I wait much longer, I'll be too sick to get the surgery."
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