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Health insurers turn away obese children for weight loss surgery

It’s hard to imagine a 12-year-old child with arteries comparable to those of a 45-year-old adult.

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But that’s precisely what a study by the American Heart Association revealed in November 2008 — and some of these children must take drugs to lower their cholesterol levels. The study found that the size of your arteries (called "vascular age") is far more important than your calendar age.

A sick generation

Your carotid arteries supply blood to the brain and doctors use the thickness of their inner lining to measure whether a patient is at risk for heart attack, stroke or other life-threatening conditions.

health insurance for obese children

"This means that children are at risk for having severe cardiovascular disease at a much younger age than their parents," says Dr. Marc Michalsky, surgical director at Nationwide Children’s Hospital in Columbus, Ohio. "If it is not reversed, they may develop heart disease in their 20s and 30s."

A child who is obese by age 12 has a 75 percent chance of becoming an obese adult, according to the American Obesity Society.

Michalsky says that the medical community only recently began sounding the alarm about medical dangers associated with morbidly obese children, but problems have always been apparent.

According to the National Institutes of Health, obesity cost Americans $125 billion in 2007. More than half of that resulted from medical costs associated with treating obesity-related illnesses. The rest was lost in wages by those unable to work due to an illness or disability. The study also found that one in 50 Americans were morbidly obese (weighing 300 pounds or more). The newest group to emerge with serious health risks resulting from obesity is children.

For adults

Adult patients suffering from obesity may be able to make insurance claims for weight-loss surgery. Read more about how to get your health insurer to pay for your weight loss surgery

In May 2008, the Centers for Disease Control and Prevention reported that 16.3 percent of American children and teenagers are morbidly obese, while an additional 15.6 percent are overweight. A body mass index of 18.5 to 25 is normal. However, when you combine a BMI of 25 to 30 with high cholesterol, you create a dangerous formula for cardiovascular disease. A person with a BMI over 40 is considered morbidly obese. To put this in perspective, morbidly obese women and men age 22 have reduced their life spans by eight to 12 years, according to the American Medical Association.

Obesity is ballooning into an even bigger health crisis because it leads to many other conditions, such as heart disease and diabetes. And when people with these conditions try to buy health insurance on the individual market as adults, they’re likely to find themselves rejected or issued policies that exclude their pre-existing conditions.

In addition, obese children will have difficulty buying life insurance for themselves as adults if they can’t reverse their conditions.

Researchers at the John Hopkins Bloomberg School of Public Health at the University of Pennsylvania published a study in July 2008 showing that if the obesity epidemic continues, total health care costs will double every decade to $956.9 billion dollars by 2030.

Insurers' reasoning

Types of weight loss surgery

Gastric Bypass Surgery (GBS): A large part of the stomach is removed and then made smaller. The small intestine is attached to the new stomach, allowing the lower part of the stomach to be bypassed.

Lap-band or Adjustable Gastric Banding (AGB): A silicone band is wrapped around the upper part of the stomach, creating a small stomach pouch. The band restricts the amount of food you can consume in a single meal. Food passes slowly from the upper to the lower stomach regions so that the patient feels full longer. (Most insurance companies will not cover this for children under 18.)

Vertical Banded Gastroplasty (VBG) or Stomach Stapling: The stomach is divided with staples and fitted with a plastic band to limit the amount of food that the stomach can hold at one time.

Roux-en-Y Gastric Bypass (RNY): The stomach is cut in half to create a pouch. It is then attached to the small intestine, bypassing a large part of the stomach and the duodenum. The procedure is effective for weight loss because the stomach pouch is too small to hold much food and bypassing the duodenum reduces the absorption of fat.

Biliopancreatic Diversion (BPD) with Duodenal Switch (DS): The first part of the procedure involves surgically reducing the size of the stomach. The pyloric valve, which regulates the release of stomach contents into the small intestine, and a segment of the duodenum, the first section of the small intestine, are left.

The next component of BPD with switch procedure is the division of the small intestine. This step separates the flow of food through the digestive tract from the flow of bile and pancreatic juices. While this reduces absorption of nutrients and fats from the small intestine into the bloodstream, it still allows the body to use digestive enzymes. The two sections of small intestine are rejoined further along the intestinal tract, near the large intestine. This allows for the normal digestion of food and enzymes. (Not covered by insurance for children.)

Source: American College of Physicians

Many blame heredity and hypothyroidism for causing obesity in children, but some people aren’t buying it.

"This notion of ‘I have a slow thyroid’ has been overplayed for years," says Michalsky. "We see very few patients that reach this level of extreme obesity when they have hypothyroidism. It’s rarely just an immunological or endocrinological issue. There are usually multiple factors involved when it comes to children with severe obesity. Environment certainly gives way to implications such as poor diet and exercise. There is also a combination of hereditary disposition and environmental impact associated with these extreme cases."

Major health insurers such as Blue Cross and Blue Shield, CIGNA, UnitedHealth Group and WellPoint offer programs for overweight children. Aetna provides consultation with a registered dietician for children ages 2 to 19 who have a BMI above the 85th percentile and one mitigating risk factor such as high cholesterol or Type 2 diabetes. Weight-management benefits through Aetna include weight-loss programs that provide discounts for memberships to fitness clubs, home exercise equipment, over-the-counter vitamins and weight-loss videos. People who have Aetna plans through work might be eligible for discounts on one-on-one consultations with nurses and dieticians, and menu-planning services. CIGNA coaches children who are overweight in order to address their problems with diet and exercise.

Blue Cross and Blue Shield and Aetna cover weight-loss surgeries for children in only special cases, and they will not cover laparoscopic or "lap band" surgery. In other words, it’s unlikely that your health plan will pay for a child’s weight-loss surgery, even if doctors deem it necessary in order to prevent premature death.

Health insurers will not pay for lap band surgery until the patient is 18 years old. For those who are eligible, insurance companies require a minimum six-month dieting regimen before they will cover the initial surgery. Others require two years of working with a behavioral therapist, combined with dieting and exercise.

Insurers’ reasoning is simple: The cost of bariatric surgery can range from $17,000 to $35,000 or more, and it is not a magic bullet. Without following a prescribed diet and exercise program, patients may not be able to maintain weight loss even after the expensive surgery. Children’s bodies are still developing and there isn’t enough evidence to prove the long-term benefits.

In addition, Wendy Morphew, a spokesperson for Aetna, says, "There has been no evidence that the same benefit of weight loss can be reached through surgery that can otherwise be reached through a more safe and practical approach like nutrition, exercise and lifestyle change for children."

Going through the back door: Clinical trials

Some parents are able to get weight-loss surgery for an obese child by entering a clinical trial. Cincinnati Children’s Hospital Medical Center is leading a five-year study on how bariatric (weight-loss) surgery affects children. Texas Children’s Hospital, Children’s Hospital of Alabama, University of Pittsburgh and Nationwide Children’s Hospital are participating. Teams of medical experts work with children for a year to change their diets and lifestyle habits and prep them for surgery. There are currently 200 adolescents in the program.

Children who come into the program usually arrive with at least two serious medical conditions such as Type 2 diabetes and high cholesterol, says Michalsky.

Although a child who is 100 pounds overweight is eligible for the program, most of the children in the program weigh nearly 300 pounds or more.

There’s also Teen-LABS (Teen-Longitudinal Assessment of Bariatric Surgery), run by the National Institutes of Health, which offers a surgery called Roux-en-Y gastric bypass surgery (RGB) for some children in the program. It has been proven to cure Type 2 diabetes in adults and children.

The National Institutes of Health does not provide funding in their "Teen-LABS" clinical trial for bariatric surgery or patient care. Study participants usually pay out of pocket for the program or rely on health insurance.

The FDA has not approved the adjustable gastric band used in bariatric surgery for patients younger than 18.

h3>Return on investment

"This is becoming an actuarial discussion," says Michalsky. "If you have a 15-year-old with diabetes, heart disease and hypertension, and you fix all of them through methods of weight loss, you are keeping them from suffering the consequences of those related diseases the next two decades of their life. Removing the disease burden of heart disease for 20 to 30 years translates to the insurance industry in a reduction in the cost of medication to maintain those diseases. You are literally reducing the cost of those health care issues decades ahead of time."

"You are literally reducing the cost of those health care issues decades ahead of time."

— Marc Michalsky

A recent initiative lead by the Alliance for a Healthier Generation (whose ads feature former president Bill Clinton) promotes prevention and wellness for overweight children. Spokesperson David Cavarocchi says that participating health insurance companies have committed to reimburse parents of overweight children for at least four visits with a primary care physician to evaluate treatment for obesity, and four visits with a registered dietician for children ages 3 to 18.

If you are a member of Blue Cross Blue Shield of North Carolina, Blue Cross Blue Shield of Massachusetts, WellPoint or Aetna you can take advantage of the program. For more information, visit the Alliance for a Healthier Generation.

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