Obesity is one of the most challenging public health problems we face as a nation. More than 32% of American adults are obese and more than 17% of children and adolescents are overweight.1
Obese individuals are more likely than normal-weight individuals to develop hypertension, heart disease, diabetes, and stroke, among other diseases.2–8
The increasing prevalence of obesity and its significant health consequences are straining our health-care system. In 2000, the total cost of obesity in the United States was an estimated $117 billion—$61 billion in direct costs and $56 billion in indirect costs.9,10
Through Medicare and Medicaid, federal and state governments finance approximately half of direct medical expenditures attributable to overweight and obesity in the U.S.11
Medicaid enrollees have the highest prevalence of obesity compared with those who are uninsured, privately insured, or in Medicare. As a result, 11% of U.S. adult Medicaid expenditures are spent on treating obesity-related medical conditions.12
In response to increasing obesity rates and the concomitant economic and health challenges these rates impose, states have responded in a variety of ways. Some have enacted tax laws that create incentives for healthy behaviors or penalize unhealthy habits.13
Some states have targeted competitive foods in schools and created new physical education and fitness requirements. Local and state governments have utilized planning, zoning, and transportation policies to promote healthier lifestyles. But few studies have examined state policy with regard to public or private insurance coverage of health-care services for obesity itself.
Currently, there are no known statutes or regulations to preclude states from covering treatment for obesity through Medicaid or private insurance. In fact, in 2004, the Centers for Medicare and Medicaid Services (CMS) removed language from the Medicare Coverage Issues Manual stating obesity was not an illness.14
And research has demonstrated that under Medicaid, eligible children already have coverage for comprehensive obesity services through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.15
EPSDT program benefits include complete periodic and as-needed assessments of children's health and development from birth to age 21. The examinations include regular assessments of nutritional status, such as height and weight measurements, and questions about dietary practices.16
For children identified with a health condition, states must arrange for all medically necessary treatments falling within federally covered service classes. Obesity assessment and treatment can be understood to fall in these covered categories. However, while eligible children are entitled to obesity assessment and treatment under EPSDT program regulations, it is not clear whether states are actually covering necessary services.
It was hoped that the 2004 CMS policy reversal would open the door to public and private coverage expansions of evidence-based obesity-related treatments. While more studies are needed to determine which therapies for obesity are most effective, treatment guidelines from the National Heart, Lung, and Blood Institute and other professional organizations concur in supporting specific multidisciplinary approaches to treatment of obesity.17–21
Despite these recommendations, public and private insurance coverage for treatment of obesity as a primary disease still appears very limited.
Most coverage expansions thus far have focused on bariatric surgery. CMS expanded coverage of bariatric surgery for Medicare beneficiaries who are morbidly obese, but beneficiaries must have a comorbid condition, such as hypertension, coronary artery disease, osteoarthritis, or type 2 diabetes.22
Some private insurers will also cover bariatric surgery on a limited basis.23
Few studies have evaluated public and private insurance coverage of primary obesity treatment, especially at the state level. In this study, we examined how states use their lawmaking and regulatory authority to respond to the problem of obesity. We conducted a state-by-state analysis of (1) Medicaid and EPSDT program coverage and payment practices for adult and pediatric obesity assessment and treatment, (2) the extent to which states prohibit or regulate insurers' medical underwriting or eligibility exclusion of obesity, and (3) the extent to which state insurance laws address coverage of obesity treatment. In previous studies of insurance coverage for obesity treatment, researchers utilized surveys to collect data from private insurers and state Medicaid programs. Our analysis is based on an extensive document and legal review of state laws, regulations, and provider guidance.