Diabetes, obesity, and the Aﬀordable Care Act
Before President Barack Obama’s landmark health law took eﬀect, obtaining aﬀordable health insurance could be diﬃcult for Americans with diabetes or obesity, if not impossible. Insurers that didn’t turn diabetic patients away could charge higher rates because these individuals had a preexisting health problem, or they could exclude coverage for certain treatments for diabetes or other chronic disorders. Companies could limit reimbursable medical expenses or even cancel coverage as medical needs increased. Now such practices are prohibited under the Patient Protection and Aﬀordable Care Act (ACA) for insurance policies purchased by individuals and small businesses through the new online health insurance exchanges, or for employment-based policies. “People with diabetes, and all Americans, can no longer be denied access to the health insurance they need, will not have their insurance run out when they need it most, and cannot be discriminated against based on pre-existing conditions, such as diabetes,” said Krista Maier, the American Diabetes Association’s associate director for public policy. And people with diabetes or obesity might be among those who best understand what the new rules mean. Average medical expenses for an American with diabetes are more than double the cost for someone without the disease, according to the ﬁrst “Diabetes Report Card” published in 2012 by the US Centers for Disease Control and Prevention, which the ACA requires every 2 years to assess data on diabetes and prediabetes, preventive care practices, risk factors, quality of care, and diabetes outcomes. “Adequate and aﬀordable health insurance is important for people with diabetes to help them access
the supplies, medications, education, and health care to manage their diabetes and prevent its devastating complications, including blindness, amputation, heart disease, and kidney failure”, said Maier . The law provides federal subsidies to individuals to purchase policies from the online health insurance exchanges to help those who can’t aﬀord insurance. And it expands Medicaid, the federal-state partnership programme of health insurance for low-income families. However, after the Supreme Court ruled that the expansion was not mandatory, 24 states have opted out. The 8 million people who enrolled in health insurance exchange policies in this ﬁrst year exceeded the Obama Administration’s goal by 2 million. Another 3 million gained coverage through the Medicaid expansion. The American Diabetes Association hopes more states will expand Medicaid “to ensure hard-working, low-income families, including those aﬀected by diabetes, who need access to aﬀordable health-care coverage, no longer have to worry about aﬀording the care they need to manage their disease”, said Maier. In addition to dramatically changing how health insurance is bought and sold in the USA, the ACA also speciﬁes what it should cover. The law lists ten “essential health beneﬁts” most policies must include and, of those, prescription drug coverage, preventive services, and chronic disease management are of most interest to people with diabetes or obesity. For example, preventive health services recommended by the US Preventive Services Task Force must be covered by most insurance policies at no cost to patients. The free services include type 2 diabetes screening, dietary and weight-loss counselling,
and blood pressure checks. The ACA also requires Medicare, the federal health programme for 52 million older or disabled Americans, to oﬀer similar preventive health services with no cost-sharing to patients. And state-run Medicaid programmes, for low-income families, that also do so will receive additional federal reimbursement. The emphasis on prevention in the ACA is particularly important for people with obesity, who can get insurance coverage for intensive behavioural therapy, and dietary counselling with no copayments. “The good news is people have better access to health insurance at a better price”, said Ted Kyle, an advocacy advisor for the Obesity Society, an organisation for scientists, physicians, nurses, and other professionals. “The bad news is that change is slow, and some of the bad habits related to how health plans deal with obesity are hanging on”, he said. Coverage for bariatric surgery for severe obesity is optional in many state health insurance exchanges. And, although these plans have to provide drug coverage, they don’t have to cover medications for obesity. By contrast, Kyle said the federal government recently told insurance carriers oﬀering coverage for federal employees that, although coverage for weight-loss drugs for obesity is not required, such drugs cannot be excluded solely because insurers consider obesity a lifestyle disorder or regard obesity treatment to be cosmetic. But health insurance plans sold on the exchanges can still deny drug coverage for these reasons, he said. The Obesity Society and other organisations have urged federal oﬃcials to extend the restriction to health insurance exchange plans.
Andy Richter/Aurora Photos/Corbis
Under the new health law, Americans with chronic disorders cannot be denied health insurance. Susan Jaﬀe reports from Washington, DC.
Lancet Diabetes Endocrinol 2014 Published Online June 9, 2014 http://dx.doi.org/10.1016/ S2213-8587(14)70122-6
www.thelancet.com/diabetes-endocrinology Published online June 9, 2014 http://dx.doi.org/10.1016/S2213-8587(14)70122-6