WASHINGTON – Like 78 million other Americans, Mary-Jane Harrison is obese.
Like many critically overweight Americans, Harrison also cannot afford to have weight loss surgery because her health insurance doesn’t cover it. That financial burden makes it almost impossible for her to follow the advice of three doctors who have prescribed the stomach-shrinking procedure for Harrison, who is 4-feet, 10 inches and weighs 265 pounds.
Harrison’s health insurance plan, provided by UnitedHealth, excludes coverage of any surgical procedures for weight loss. As a result, she and her family are trying to raise $15,000 to pay for the surgery that she said will save her life.
“I am now 53, and I don’t think I’m going to live to be 55,” said Harrison, 53, who lives outside of San Antonio and has tried for years to lose weight through dieting and exercise. “When you feel your health deteriorating this fast, you know it.”
UnitedHealth said it cannot comment on Harrison’s health plan unless she signs a privacy waiver. But Harrison declined to sign one due to concerns about how the company might use the information.
Harrison’s case underscores a surprising trend: While the number of obese Americans persists at record levels, the number of patients undergoing weight loss surgery hasn’t budged in a decade.
About 160,000 U.S. patients underwent weight loss surgery in 2013, roughly the same number as in 2004. That’s only about 1 percent of the estimated 18 million adults who qualify nationwide for the surgery, the American Society for Metabolic and Bariatric Surgery said.
“If we were talking about breast cancer, no one would be content with having only 1 percent of that population treated,” said Dr. John Morton, professor of surgery at Stanford University. “Yet if you look at the impact of obesity on life expectancy, it’s by far one of the most dangerous conditions we have in public health.”
Surgeons blame a combination of factors for the stagnating numbers, including the economic downturn and a social stigma against resorting to surgery to treat weight problems. But insurance coverage is the largest hurdle, they said.
Almost two-thirds of health plans sponsored by employers don’t cover weight loss surgery, which can cost from $15,000 to $25,000. Those that do often mandate that patients meet a number of requirements, including special diets and psychological evaluations, before they can get the procedure covered.
Early signs indicate many of the same challenges seen in the private market have carried over to the new, state-run insurance exchanges that are part of the health care overhaul. Only 24 states require insurers to cover weight loss surgery for patients. When the procedure is covered, many plans require patients to pay up to 50 percent of the cost out of pocket.
Insurers have said for years that bariatric surgery should only be used as a last resort, hence the many preliminary requirements and evaluations.
“All major surgeries are risky. This one is life altering, and if there is an approach that’s less invasive and less risky for the patient, you want to try that one first,” said, Susan Pisano, a spokeswoman for America’s Health Insurance Plans, an insurance industry trade group.
But the insurance hurdles are pushing up against new medical guidelines urging doctors more aggressively to address obesity, including referring patients for surgery. Guidelines issued in November by the American Heart Association, the American College of Cardiology and the Obesity Society call on doctors to calculate a patient’s body mass index – an estimate of body fat based on weight and height – each year, and recommend surgery for those who face the most serious health problems.
More than a third of U.S. adults are obese – defined as someone with a BMI of 30 or higher – and that’s been the case since the middle of the last decade. Weight loss surgery is recommended for those with a BMI of 40 or those with a BMI of 35 who have other risk factors for heart disease such as diabetes or high blood pressure. A 5-foot-9 person would be obese at 203 pounds.
The most popular procedure is gastric bypass, which involves stapling off a small pouch from the rest of the stomach and connecting it to the small intestine. Patients eat less because the pouch holds little food, and they absorb fewer calories because much of the intestine is bypassed.
Another procedure called gastric banding places an inflatable ring over the top of the stomach to restrict how much food it can hold.
The latest long-term studies show that the typical patient loses about 30 percent of their excess weight with the bypass procedure and 17 percent with the band after three years. That compares with weight loss of 2 percent to 8 percent with diet and lifestyle changes.