The workshop took place during a time of heightened debate around health policy with respect to the Patient Protection and Affordable Care Act (ACA) and other health-related legislation, noted Lisel Loy, vice president of programs for the Bipartisan Policy Center and moderator of the panel on policy considerations. A panel of four experts, including two Capitol Hill
staffers and two advocates for obesity initiatives, reflected on the current scene and on the potential for progress.
The ongoing activity in the health policy world “presents a lot of opportunities to move forward on legislation, in particular in a bipartisan manner,” said Matt Gallivan, health policy advisor for Senator Bill Cassidy, a Republican from Louisiana who is a physician and worked in the charity care system in Louisiana for 25 years. Gallivan explained that beyond the debate over the ACA, more legislators are coming to understand the impact that patients with multiple chronic conditions are having on the federal budget, state budgets, and the social safety net, and the importance of access to high-quality care for improving patient outcomes. “There is a bipartisan recognition of that having to be an area of focus, and a large driver of that is patients combating obesity,” he said.
Gallivan cited the Treat and Reduce Obesity Act,1 which is focused on increasing coverage, particularly in the Medicare space, as one example of proposed legislation that has attracted bipartisan support. He added that the Senate Finance Committee, of which Senator Cassidy is a member, also has done work on chronic care. “There is some good bipartisan synergy going on,” he asserted, “despite the larger, frankly more partisan conversations around the ACA.”
Gallivan pointed out that Congress needs input on innovative care delivery models and the barriers faced in delivering care, such as reimbursement issues, regulatory issues, lack of coverage, and patient engagement. “We have to have serious conversations about these issues so that we can get at the cost drivers and focus on the growing patient group that is driving a lot of the higher costs and worse outcomes,” he suggested.
Lynn Sha, senior health policy advisor for Senator Thomas Carper of Delaware, also emphasized the bipartisan opportunities that exist in health policy. She observed that Delaware is a collegial state in which people work across party lines. “There is a lot of effort to work together in a practical way that is fiscally responsible,” she explained, “but also trying to make sure that the most vulnerable people in our communities are not left behind.” She argued that the same approach can work in Washington, DC. “There actually are a lot of areas of agreement, a lot of areas where people feel like we need to work together to get something done. . . . Please don’t be too discouraged by what you hear [in the news]. There is a lot of
1 Treat and Reduce Obesity Act of 2017 [HR.1953/S.830], https://www.congress.gov/bill/115th-congress/house-bill/1953 (accessed November 14, 2017); https://www.congress.gov/bill/115th-congress/senate-bill/830 (accessed November 14, 2017).
effort behind the scenes to try to come together on some of these major priorities.”
Obesity is one of these priorities, Sha added. She noted that the Treat and Reduce Obesity Act, which had more than 150 cosponsors in the House and 10 in the Senate at the time of the workshop, has always been bipartisan. She cited the requirement under the ACA that people have access to preventive treatments (including counseling for weight reduction) without cost sharing and the Diabetes Prevention Program as examples of successful approaches, although their uptake has to date been low. “We collectively have to figure out how we get to a better place on those kind of things,” she argued. One important step will be to develop better measures, she suggested, because “you can’t manage what you can’t measure.” She gave as an example better measures of how many people are receiving counseling under Medicare and Medicaid, which would provide a baseline against which to improve.
Sha also asserted that more thought needs to be given to how to reverse negative trends in nutrition, physical activity, and other drivers of obesity. “Everyone agrees we have to do something on obesity,” she said. “What is less clear is how we pay for it.” She noted that many Senate committees are involved in the financing of health care, and they all have common interests in reducing obesity. “This is an area where there is a lot of room for consensus and a lot of room to grow,” she suggested.
Sha reminded participants of the value of referring to “one of the few bright lights that we have seen”—the plateauing of childhood obesity. When her children come home talking about whether to eat snap peas raw or cooked, she is impressed that “they actually know what a snap pea is.” Everyone, whether Democrat or Republican, can agree on the need to have access to and eat more fruits and vegetables, she observed. “That is the kind of winning message that we should all try to work toward,” she said.
Anand Parekh, chief medical advisor for the Bipartisan Policy Center, asserted that the greatest recent improvement in obesity treatment was the coverage of 20 million more Americans by the ACA, including 10 million Americans covered through the Medicaid expansion provision. In addition, he noted, Section 2713 of the ACA required that private plans cover U.S. Preventive Services Task Force recommendations with grades of A or B, including obesity screening and counseling for children and adults, without cost sharing. The ACA also extended this policy to Medicare beneficiaries and the Medicaid expansion population (see Chapter 8 for further information). Another major impact of the act, Parekh observed, was through its Community Transformation Grants under the Prevention and Public Health Fund, which led to investments in communities across the country to help prevent chronic diseases such as obesity, diabetes, and heart disease. He noted that although relatively few data have been generated regarding
the impact of the ACA on obesity, some progress is being made in improving care delivery. As an example, he cited the creation of the Center for Medicare and Medicaid Innovation, which has supported the development and testing of innovative health care payment and service delivery models leading to expansion of the Diabetes Prevention Program in Medicare. He added that obesity screening is now part of most alternative payment models as a process quality measure.
Parekh emphasized that approaches to obesity must involve both the clinical side and the community side, and community initiatives will likely provide the greatest return on investment. He suggested that one way to incentivize such initiatives, which could reinforce reforms in medical care and policy systems and environmental change, would be to offer communities matching grants and prioritize disadvantaged communities so that existing disparities do not increase.
Parekh reported that the Bipartisan Policy Center has promoted the idea of a secretarial task force on obesity that would focus on prevention as well as treatment. He observed that the Obama administration made major progress on obesity with the ACA, the First Lady’s Let’s Move Initiative, and actions by the Centers for Disease Control and Prevention (CDC). “But,” he added, “we have never had a high-level secretarial task force with agency heads focused on prevention and treatment where one could coordinate the activities of CDC, CMS [the Centers for Medicare & Medicaid Services], and all the federal agencies.”
Parekh described another proposal to use the quality measures developed by CMS to pursue delivery and payment reform. Measures for obesity screening are “great,” he suggested, but outcome measures for quality also are needed. “We need to put providers, hospitals, and health care systems on the hook for the prevalence of obesity amongst their patient population, and/or for percentage weight reduction as well,” he asserted. “It is not good enough just to screen. Once we do that, once we put providers on the hook, then all of the community evidence-based treatments that you have talked about today can be further integrated into the health care system.”
Echoing a point made by the other speakers, Parekh observed that obesity policy should not be a partisan issue. “Both Republicans and Democrats are equally invested in this,” he asserted. At the same time, he said, policy makers need to hear on a continual basis that obesity is a critical issue: “Policy makers need to understand that there is no bigger health policy issue today than obesity. Obesity impacts cost, it impacts disability, it impacts chronic diseases in ways that really no other [health concern], whether a chronic condition or a comorbidity, does. It is fine talking about the financing of the health care system. It is fine talking about delivery of the health care system. But if you don’t tackle obesity—which is, with to-
bacco, the leading risk factor driving chronic conditions—we are not going to solve any of our issues.”
The Obesity Action Coalition is a 55,000-member patient advocacy organization made up primarily of people with obesity. “Ninety percent of them have obesity, just like I do,” said Joseph Nadglowski, the coalition’s president and CEO. “I have spent the last 12 years—12 years this week—working on trying to influence public policy around obesity, primarily on behalf of those who already have obesity.”
The Obesity Action Coalition has been working to pass the Treat and Reduce Obesity Act, which Nadglowski termed “important legislation.” The act applies to Medicare, he noted, but private insurers often follow what Medicare does. “It will not only benefit our senior citizens and those who are disabled,” he said. “It should benefit us all if we pass that legislation.”
Nadglowski, too, stressed that obesity is a bipartisan issue. “In my 12 years of doing this,” he said, “I have had equal success working with Democrats and Republicans at both the state and the federal level.” For that reason, he added, talking with elected officials about obesity is relatively easy, because “you are wearing a white cape when you go in there—you are the superhero.”
Nadglowski cited as a major challenge is that obesity prevention and treatment does not have a large number of champions among policy makers. “Every legislator I have ever talked to is interested in addressing obesity,” he said, “but we have had trouble getting them to make it that number one, number two, or number three issue. . . . Unless it rises to that level, it is hard to move something forward.”
Part of the reason for this lack of policy emphasis is bias, Nadglowski suggested. Policy makers assume that people should deal with the issue on their own, he observed, not through policy initiatives. He argued that even legislators who are affected by obesity themselves are less likely to step forward to become a champion of this disease because of bias, self-blame, and shame.
Nadglowski also placed part of the blame for the lack of champions on the communities that work on obesity. “We go forward with these very diverse messages,” he said, “and we get caught up in our areas of expertise or our areas of focus. I am the food guy or I am the exercise guy or I am the environment guy or I am the treatment guy or I am the drug guy or I am the surgery guy. We need to go forward with a universal approach to address this. It is not one thing that is going to solve obesity. It is all of those things.”
According to Nadglowski, the main benefit of the ACA to people with obesity was that it prevented them from being denied coverage because their obesity was preexisting. It also required that particular services be covered, but that has happened to a far lesser extent, he observed. “There is a big difference between having the law written and then having the rules enforced,” he noted. In some places, for example, bariatric surgery is considered essential, but that is not the case in other places. “We have the haves and have-nots when it comes to medical coverage,” he asserted.
Nadglowksi emphasized the importance of dealing with what he called the blame and shame issue. “Many of us will say, ‘I will go talk to my doctor about my weight after I lose 10 pounds,’” he observed. “We have to stop that. We have to make it so that people realize that they are not solely to blame for this. We have options available for them.”
Nadglowski emphasized that “when we turn this into real people, it is a lot easier for those legislators to listen.” He argued that patients are better than physicians at convincing a legislator that obesity is a serious issue. “Many of you, through the programs you run, have wonderful stories,” he said. “Bring those folks with you to the Hill. That is what will change someone’s mind.” He also emphasized the importance of language: “I am not obese. I have obesity. It is important. Obese is an identity. Don’t make me think that that is all I am, that I am obese. I am a person who has a condition. Subtle changes like that will make a big difference in the long run.” Refusing to use the word “obese” was not easy, he noted. “It took me 2 years of stuttering every time I would say it—‘oh, I mean person with obesity.’ I am challenging you to stutter.”
Changing public perceptions is critical, Nadglowski asserted. “We can work with the policy makers all we want,” he said. “Until the public comes out and demands this, it is going to be hard to make this a number one or number two issue. [It requires] reaching out to folks and saying, ‘Hey, it is okay that you have obesity. This is a disease. Let’s deal with it. [And] it is okay for you to step up and ask for the help you need.’”
A prominent topic of discussion during the question-and-answer session was the need for new initiatives to heighten the visibility of obesity prevention and treatment. Loy noted that new initiatives often achieve more change when they intersect with ongoing work, such as the Senate’s Chronic Care Working Group: “We have looked hard at existing opportunities where members are already engaged on issues that they care about that may or may not carry the label obesity, but that would enable them to engage on these issues.”
Parekh observed that the creation of a secretarial task force “only gets
you so far,” but it is a step in the right direction. One thing such a task force could do, he suggested, is coordinate implementation across agencies, because having the right policy is one thing, but implementation is another.
Gallivan agreed that coordination across agencies is important, as is focusing on obesity as an underlying contributor to chronic diseases. Also, he argued, giving Medicaid and other federal programs more flexibility so that states can experiment with opportunities to implement targeted population health management could lead to important innovations. As an example, he cited the National Institutes of Health’s Brain Research through Advancing Innovative Neurotechnologies® (BRAIN) Initiative, which brought together groups focused on different neurological diseases because advances could help them all.
Sha pointed out that pulling people together to address obesity is a great idea but is not sufficient in and of itself. “We need more legislation,” she asserted. “We need more people engaged. We need more champions.” In comparison with a secretarial task force, she added, congressional commissions can have a greater impact, especially because “Congress probably needs some advice on how we get at all of these broader issues.” That, she suggested, would help integrate consideration of obesity “into every single piece of our policy-making apparatus and policy execution and implementation.”
This page intentionally left blank.