obesity: progress and challenges

By Amy Winterfeld and Richard Cauchi | Vol . 22, No. 18 / May 2014

NCSL NewsDid you know?

  • The American Medical Association recognizes obesity as a disease.
  • New health insurance policies sold to individuals and small employers must now cover obesity screening and counseling at no cost to enrollees.
  • Obesity has become the most common medical disqualifier for military service.

Obesity, a common and costly health issue, affects more than one-third of adults and 17 percent of youth in the United States. By the numbers, 78 million adults and 12 million children are obese—figures many regard as an epidemic. Adults are considered obese when they are about 35 pounds overweight, as are children whose body mass index is at or above the 95th percentile for children of the same age and sex. Being obese increases the risk for heart disease, stroke and type 2 diabetes—the first, fourth and seventh leading causes of death, respectively—and contributes to more than one in five cancer-related deaths. The American Medical Association recognized obesity as a disease in 2013 and the American Academy of Pediatrics recommended obesity prevention, assessment and patient counseling in 2007.

Obesity-related health care spending continues to grow, with researchers estimating medical costs at $147 billion annually, including $7 billion for Medicare prescription drugs. Medicare and Medicaid pay for between 22 percent (Virginia) and 55 percent (Rhode Island) of state-level costs attributable to obesity. In addition, obesity is the most common medical disqualifier for military service, affecting about 25 percent of applicants.

No state currently has an adult obesity rate of less than 20 percent, but recent research may show signs of progress in young children. One study conducted by the Centers for Disease Control and Prevention observed a decrease in obesity prevalence among low income preschoolers in 19 U.S. states and territories between 2008 and 2011. Because obesity prevalence remains high, however—increasing by roughly 20 percent for adults and 30 percent for children during the past 30 years—it remains a pressing public health concern.

Federal Action

Medicare first recognized obesity as a medical condition in 2004 and began covering interventions when scientific evidence demonstrated their effectiveness. In 2011, Medicare issued a Coverage Decision memorandum outlining requirements for intensive behavioral counseling and therapy for beneficiaries affected by obesity.

Under the Affordable Care Act (ACA), state Medicaid programs must design public awareness campaigns to educate enrollees about available coverage for obesity screening and other preventive services. The ACA also provides an enhanced federal Medicaid matching rate for states that cover certain preventive services without cost-sharing, including screening adults for obesity and offering those who qualify intensive behavioral interventions.

Spurred in part by First Lady Michelle Obama’s Let’s Move initiative, the federal government has increased its focus on combating obesity in the general population. Federal initiatives—such as the National Prevention Strategy, Community Transformation Grants, the Healthy Food Financing Initiative, Healthier US Schools Challenge, and the U.S. Department of Agriculture’s programs that provide healthy food to children— aim to reduce disparities and foster healthier choices for Americans.

State Action

Many state policies help treat or prevent obesity. States have launched several Medicaid outreach efforts, including Massachusetts’ “Mass in Motion,” Missouri’s PHIT Kids (Promoting Health in Teens and Kids) weight management program and the Texas Medicaid Child Obesity Prevention Pilot.

In 23 states**, bariatric surgery is now covered by most insurance plans after the ACA in 2012 allowed states to select “benchmark” plans that included the surgery. Two other ACA rules affecting states went into effect Jan.1. One prohibits most insurance policies, including those sold through exchanges, from levying premium surcharges for being obese. The other requires most insurance plans to cover certain services without cost-sharing, including obesity screening and counseling for all adults and children.

State lawmakers have also adopted numerous prevention policies that create choices for healthy eating and active living in schools, communities and workplaces. Such strategies include:

  • Increasing access to healthy food with public-private incentives for grocery retail development, and bringing fresh produce to schools and communities through farm-to-school programs, farmers’ markets and community gardens.
  • Applying school nutrition standards, such as those for food and beverages in California and Texas; providing drinking water in schools and child care facilities; offering healthier school snacks; and increasing the availability of nutritious school meals, such as Colorado’s Breakfast After the Bell Nutrition Program and West Virginia’s Feed to Achieve initiative.
  • Establishing school wellness programs, such as Rhode Island’s local school wellness committees, and workplace wellness efforts, such as South Carolina’s.
  • Requiring quality physical education (P.E.) and physical activity in schools to increase student fitness and academic achievement, such as Illinois’ efforts to enhance P.E.
  • Promoting physical activity in community settings, such as complete streets with sidewalks, crosswalks and traffic-calming designs that make walking and bicycling safer.

Facilitating joint or shared-use agreements such as Arkansas’ program that enables community members to use school recreational facilities for physical activity when not in use by student.

**Three additional states in the NCSL online table (GA, IN, and VA) provide that "coverage must be offered..." in at least some policies, but it is not required in all policies. [Clarification and 23 state total added to this report 7/1/2015]

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