Obesity and Health Insurance: Overview

Introduction

Obesity is a medical condition usually defined by a person’s body mass index (BMI) but also used as a general term for persons who have an excessive amount of body fat. The World Health Organization (WHO) classifies anyone with a BMI higher than 30 as “obese,” while those above 40 are considered “severely” or “morbidly” obese by the WHO and other health institutions. In addition to BMI, measurements such as waist circumference and body fat percentage are used to determine obesity. For men, 25 percent body fat is considered obese, while 35 percent is considered obese for women. None of the methods are completely accurate, and they are often combined to create a clearer picture of a particular person’s risk factors.

The increasing prevalence of obesity has caused concern due to its association with serious health conditions, including hypertension, type 2 diabetes, heart disease, and some cancers. The CDC also estimated that the medical cost of obesity in the United States was close to $173 billion (2019 dollars) and that adults with obesity incurred $1,861 more in medical costs compared to people with healthy weight. Yet, Medicaid and most commercial health insurers do not cover bariatric surgery or medications known to cause weight loss, such as semaglutide, as treatments solely for weight loss. By 2024, the debate over whether weight loss treatments should be covered by health insurers centered on whether weight loss should still be considered a cosmetic issue, and therefore ineligible for coverage, or whether treatments for obesity should be covered like any other medical problem.

Understanding the Discussion

Body fat: The amount (usually expressed as a percentage) of fat in a person’s body. Body fat plays an important role in human health, and some is necessary for maintaining many bodily processes and functions such as regulating temperature, providing cushioning, and insulating organs. Too little body fat (less than 10 percent in women or less than 2 percent in men) is unhealthy because it impairs these functions, while too much (more than 30 percent for women or more than 25 percent for men) is also unhealthy because it overtaxes the body and organs.

Body mass index (BMI): An expression of weight in kilograms divided by height in meters squared. Because BMI does not directly measure body fat, it is not entirely accurate for determining obesity, especially since muscle weighs more than fat, making it possible for a very muscular person to have a higher BMI than an obese person.

Epidemic: Medically, a disease in which new cases appear in numbers far greater than what is expected. Used metaphorically, an epidemic can refer to any condition or behavior that spreads like a medical epidemic.

Obesity: Generally, an extreme excess of body fat. Persons in the 95th percentile of weight, or with a BMI of 30 or more, or with more than 30 percent (25 percent for men) body fat, are usually considered obese. Obesity occurs when more calories are consumed than are burned. However, the rate at which calories are burned varies widely between persons and for a number of reasons, so no one cause can be definitively blamed for obesity.

Overweight: A less-technical term than “obese,” a term that is usually applied to persons with a BMI above 25. Unlike obesity, which deals specifically with body fat, overweight can refer to any excess weight, whether caused by fat, muscle, bone, or water.

History

Obesity itself has existed for as long as people have existed, though the stigma attached to it is fairly recent, Western phenomenon. In many cultures, both ancient and modern, obesity is seen as a sign of health, fertility, and attractiveness. Where obesity was once a symbol of opulence and wealth, with an increased understanding of the causes and effects of obesity, most people have come to see it as an undesirable condition to be avoided.

Between the 1980s and the 2000s, obesity in the United States doubled among adults. Furthermore, the number of children above normal weight had doubled, and the number of adolescents above normal weight had tripled. Many plausible causes for this increase were suggested, including lack of activity, less expensive and less nutritious food, increased food production, as well as numerous social factors. There was no real consensus on the reason for this extraordinary increase in obesity, and it was likely a combination of several or all of these.

In the 1995, a popular diet drug known as fen-phen, a combination of fenfluramine and phentermine, became known as a miracle drug for weight loss after a four-year study of 121 obese patients showed that subjects who took the combo had lost an average of thirty pounds. More than 18 million prescriptions for fen-phen were filled in 1996 alone, and the FDA approved what was thought to be a more effective form of fenfluramine, dexfenfluramine. Fenfluramine and dexfenfluramine were pulled from the market in September 1997, however, after reports that their use was associated with increased risks of serious and otherwise rare heart valve problems and pulmonary hypertension.

In the 2000s, the two major positions on obesity were “personal responsibility” and “public interest,” with the former encouraging obese people to accept the problem as one of their own making, and thus curable only through their own efforts, and the latter pushing for governmental regulations akin to those applied to tobacco products. The personal responsibility attitude was the more prevalent in American culture and was reflected in policy.

With the enactment of the Medicare Modernization Act of 2003, the federal government prohibited Medicare from covering weight loss medications, deeming them too risky to use for a cosmetic purpose such as slimming down one's physical appearance. In 2004, the US Department of Health and Human Services retracted its official position that obesity is not a disease, but it stopped short of positively declaring it a disease and thus creating the possibility that obesity-related conditions could be covered by insurance. The public interest view advocated for regulations against entities, such as fast food restaurants, that they claim contribute to the so-called obesity epidemic, pushing for both better consumer education and stricter penalties for companies that promote unhealthy lifestyles.

In 2008, medical costs related to adult obesity totaled $147 billion, or roughly 9 percent of America’s total health costs, with estimates for 2030 increasing by between $48 billion and $66 billion. Though much of this was covered by insurance, obese people paid 56 percent more in per-person medical expenses than normal-weight adults. At the time, polls showed that Americans supported policies that would raise health insurance rates for obese people, as was the case for smokers. Despite the increased costs, most insurance companies did not charge increased rates for obesity, which many people said would create extra incentive for obese people to lose weight. However, insurance companies also rarely covered obesity-combating programs to the same degree that they covered smoking cessation programs and products.

The Affordable Care Act (ACA), which was signed into law by US President Barack Obama in 2010, included several provisions aimed at curtailing the problem of obesity in America. These included expanded coverage to lower the cost of bariatric surgery and the requirement that insurance companies provide coverage for obesity screening and nutritional counseling. Despite a stipulation in the ACA that insurance companies could no longer charge insurers more for pre-existing conditions, overweight individuals who did not participate in their employer’s wellness programs could be charged 30 percent more for their health insurance than those who participated.

In December 2017, the FDA first approved injectable semaglutide (Ozempic), for the treatment of type 2 diabetes in adults. The drug was intended to be used with diet and exercise to improve glycemic control, but clinical studies showed that subjects on Ozempic for over five years lost an average of 17 percent of their body weight and were able to keep it off as long as they continued to take the medication. In 2020, the FDA approved the use of semaglutide by adults with type 2 diabetes and cardiovascular disease to reduce the risk of major adverse cardiac events. The following year, the FDA approved a similar, higher-dose semaglutide injection, marketed as Wegovy, for chronic weight management in adults with obesity or overweight and one other weight-related condition. Other patients who wanted to lose weight but who did not have diabetes or another weight-related condition, sought off-label prescriptions for the drugs even though insurance companies would not cover the costs, which were significant. List prices ranged from more than $900 (Ozempic) to $1,300 (Wegovy) out of pocket for four weeks' worth of injections, and patients were expected to stay on the drugs indefinitely to treat their chronic conditions and maintain weight loss. Despite the expense, the drugs became so popular for weight loss that demand often outstripped supply, leaving patients who were prescribed them as indicated and had insurance coverage unable to find them. Both expense and scarcity prompted some patients to look for alternate, less expensive, and more risky formulations of semaglutide.

Obesity & Health Insurance Today

By the 2020s, 70 percent of US adults either had obesity or overweight. The prevalence of obesity was about 42 percent for US adults overall, but varied among different demographic groups. Non-Hispanic Black adults had the highest, age-adjusted obesity rate, at 49.9 percent, compared to Hispanic adults at 45.6 percent, non-Hispanic White adults at 41.4 percent, and non-Hispanic Asian adults at 16.1 percent. For adults aged twenty to thirty-nine years, the obesity rate was 39.8 percent, compared to a rate of 44.3 percent among adults aged forty to fifty-nine and 41.5 percent of adults aged sixty and older.

In 2022, the FDA approved another drug, tirzepatide (Mounjaro) for the treatment of type 2 diabetes but not for weight loss, even though its manufacturer, Eli Lily, stated on its website that Mounjaro users experienced weight loss of up to twenty-five pounds. A major 2021 study had showed that subjects on tirzepatide lost more weight and had greater reductions in blood sugar than those on semaglutide, but researchers cautioned that different doses of the two drugs had been compared and that long-term effects of tirzepatide were still unknown. In November 2023, the FDA approved tirzepatide, marketed as Zepbound, for chronic weight management in patients with obesity or overweight who also had another weight-related condition.

That same month, the American Medical Association (AMA) formally called on health care insurers to cover anti-obesity medications (AMOs) for weight management alone, stating that obesity is a disease that presents a major health concern to the US and that, if left untreated, puts patients at risk of serious adverse health outcomes. The AMA and other pro-coverage advocates argued that coverage of AMOs would reduce the out-of-pocket costs for patients, thereby increasing their access. The AMA had officially categorized obesity as a disease in 2013, but by 2024, Medicare and about 75 percent of commercial health care insurers still considered AMOs "vanity drugs" and would only cover them if they were prescribed for diabetes or another weight-related condition. In fact, by mid-2023, insurers began to send warning letters to physicians and health care providers suspected of prescribing Ozempic off label for weight loss. Medicare did cover obesity treatments such as behavioral therapy and, in cases of severe obesity, bariatric surgery.

These essays and any opinions, information, or representations contained therein are the creation of the particular author and do not necessarily reflect the opinion of EBSCO Information Services.

Bibliography

Abrams, Rachel, and Katie Thomas. “In Health Law, a Boon for Diet Clinics.” The New York Times, 5 July 2015, pp. 1-14. EBSCOhost, . Accessed 18 Feb. 2016.

"Adult Obesity Facts." Centers for Disease Control and Prevention, 17 May 2022, www.cdc.gov/obesity/data/adult.html. Accessed 18 Apr. 2024.

"AMA Urges Insurance Coverage Parity for Emerging Obesity Treatment Options." AMA, 14 Nov. 2023, www.ama-assn.org/press-center/press-releases/ama-urges-insurance-coverage-parity-emerging-obesity-treatment-options. Accessed 18 Apr. 2024.

“American Society for Metabolic and Bariatric Surgery, Obesity Groups Take Aim at States That Deny Coverage of Obesity Treatment under Affordable Care Act.” Bariatric Times, vol. 12, no. 12, 2015, p. 26. EBSCOhost, . Accessed 18 Feb. 2016.

Bray, George A., and Claude Bouchard. Handbook of Obesity. Informa Healthcare, 2003.

Cawley, John H. Jr. The Oxford Handbook of the Social Science of Obesity. Oxford UP, 2011.

"Does Insurance Cover Weight Loss Medication?" Obesity Medicine Association, 18 Dec. 2023, obesitymedicine.org/blog/does-insurance-cover-weight-loss-medication/. Accessed 18 Apr. 2024.

"FDA Approves New Medication for Chronic Weight Management." U.S. Food & Drug Administration, 8 Nov. 2023, www.fda.gov/news-events/press-announcements/fda-approves-new-medication-chronic-weight-management. Accessed 19 Apr. 2024.

Gaesser, Glenn A. “Examining the ‘Obesity Costs’ Statistic.” Health at Every Size, vol. 18, no. 6, Nov. 2004, pp. 90-91. EBSCOhost, . Accessed 22 Aug. 2008.

Gard, Michael, and Jan Wright. The Obesity Epidemic: Science, Morality and Ideology. Taylor, 2005.

Goodman, Brenda. "Insurance Denials for Popular New Weight Loss Medications Leave Patients with Risky Choices." CNN, 8 Jan. 2024, www.cnn.com/2024/01/08/health/weight-loss-drug-insurance-denials/index.html. Accessed 18 Apr. 2024.

Kolata, Gina. "How Fen-Phen, a Diet 'Miracle,' Rose and Fell." The New York Times, 23 Sept. 1997, www.nytimes.com/1997/09/23/science/how-fen-phen-a-diet-miracle-rose-and-fell.html. Accessed 19 Apr. 2024.

Kolata, Gina. "The Doctor Prescribed an Obesity Drug. Her Insurer Called It ‘Vanity.’" The New York Times, 31 May 2022, www.nytimes.com/2022/05/31/health/obesity-drugs-insurance.html. Accessed 18 Apr. 2024.

Levy, Lance. Understanding Obesity: The Five Medical Causes. Firefly, 2000.

Lytle, Leslie. “Dealing with the Childhood Obesity Epidemic: A Public Health Approach.” Abdominal Imaging, vol. 37, no. 5, 2012, pp. 719-24. EBSCOhost, . Accessed 2 Jan. 2013.

Munk, Cheryl Winokur. "Most Employer Health Plans Don't Cover New Blockbuster Weight Loss Drugs, But That's Going to Change." CNBC, 16 Feb. 2024, www.cnbc.com/2024/02/16/what-you-need-to-know-about-health-coverage-for-new-weight-loss-drugs.html. Accessed 18 Apr. 2024.

Myers, Candice A., et al. “Change in Obesity Prevalence across the United States Is Influenced by Recreational and Healthcare Contexts, Food Environments, and Hispanic Populations.” PLoS ONE, vol. 11, no. 2, 2016, pp. 1–12. EBSCOhost, . Accessed 18 Feb. 2016.

Oliver, J. Eric. Fat Politics: The Real Story behind America’s Obesity Epidemic. Oxford UP, 2006.

Schechter, Carol. “Taking Action to End the Obesity Epidemic.” Policy & Practice of Public Human Services, vol. 66, no. 1, Mar. 2008, pp. 20–21. EBSCOhost, . Accessed 21 July 2009.

Vafiadis, Dorothea. "Obesity Treatment and Medicare: A Guide to Understanding Coverage." National Council on Aging, 27 Feb. 2024, www.ncoa.org/article/obesity-treatment-and-medicare-a-guide-to-understanding-coverage. Accessed 18 Apr. 2024.

“Who Pays in the Obesity War.” Lancet, vol. 363, no. 9406, 31 Jan. 2004, p. 339. EBSCOhost, 22 Aug. 2008.

Witt, Louise. “Why We’re Losing the War against Obesity.” American Demographics, vol. 25, no. 10, Dec. 2003, pp. 26-31. EBSCOhost, earch.ebscohost.com/login.aspx?direct=true&db=a9h&AN=11755510&site=ehost-live. Accessed 22 Aug. 2008.

Youfa Wang, et al. “Race, Place, and Obesity: The Complex Relationships among Community Racial/Ethnic Composition, Individual Race/Ethnicity, and Obesity in the United States.” American Journal of Public Health, vol. 102, no. 8, 2012, pp. 1572-78. EBSCOhost, . Accessed 2 Jan. 2013.