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Nearly two-thirds of Virginians were overweight or obese in 2021, according to a new report by the Joint Commission on Health Care.
The study, which examined obesity and eating disorder prevention and treatment in Virginia, was mandated by resolutions passed by the General Assembly in 2022.
This story was reported and written by The Virginia Mercury
Overall, it shows obesity prevalence is disproportionately higher in non-White and lower-income groups. Individuals with lower income are more likely to be obese, while individuals with higher income are more likely to be overweight. About 47% of Black individuals and 30% of Hispanic individuals were obese in Virginia in 2021, despite accounting for 18% and 10% of the state’s population, respectively.
Obesity also appears to be spiking among Medicaid members. Analyst Estella Obi-Tabot told commission members Oct. 18 that obesity diagnoses among Virginia Medicaid members rose 222% between 2014 and 2021 — a stark contrast to the approximately 4% increase in diagnoses among the general population.
Eating disorder cases among Medicaid members also more than tripled — rising by 290% — between 2014 and 2021, with a notable spike during the beginning of the COVID-19 pandemic. Women and white individuals were most likely to have an eating disorder, while American Indian and Alaskan Native individuals exhibited disproportionately high rates of eating disorders.
Overall, the report estimates 9% of Virginians will have an eating disorder in their lifetime.
Barriers to care
The report found limited coverage and Medicaid provider reimbursement rates were key factors that prevented many Virginians from accessing treatment for obesity and eating disorders.
Obi-Tabot said obesity treatment falls into three categories: behavioral interventions like weight loss programs, pharmacotherapy such as weight management medications, and bariatric surgery for weight loss. However, not all insurance plans cover all forms of treatment.
Virginians with individual and small group plans through the state marketplace currently have coverage for 10 federally mandated categories of essential health benefits, including emergency, mental health and substance use disorder services. And starting in 2025, Virginia’s expanded essential health benefits benchmark plan — the state’s requirements for what individual and small group health insurers must offer enrollees — will include additional benefits like coverage for certain nutrition products that are used as medicine.
However, those requirements don’t include coverage for medical nutrition therapy — nutrition-based treatment provided by a registered dietitian — for people who don’t have diabetes, weight loss drugs, bariatric surgery or weight loss programs, even if medically advised.
Medicaid enrollees do have coverage for certain weight loss drugs with prior authorization and bariatric surgery if the procedure is considered medically necessary.
Obi-Tabot also said Virginia Medicaid has piloted an evidence-based National Diabetes Prevention Program targeting people who are at high risk for type 2 diabetes, but it is not yet available in Virginia.
According to the Mayo Clinic, being overweight or obese are main factors that increase the risk of type 2 diabetes.
For eating disorders, Obi-Tabot said a combination of evidence-based mental and physical health treatment strategies, ranging from outpatient therapy to inpatient hospitalization programs, can help.
However, Medicaid providers and insurers that offer plans through the state marketplace told researchers that low and inconsistent reimbursement rates and limited coverage for treatment services are unsustainable and confusing.
“How does what we cover matter if nobody will take the payment?” Del. Dawn Adams, D-Richmond, asked the committee.
Moving forward
Obi-Tabot presented several policy options to the committee on how Virginia can address and reduce the current barriers to care for obesity and eating disorders.
On obesity, the report recommends developing a plan to cover the Diabetes Prevention Program under Medicaid and remove annual limits for medical nutrition therapy services. Other recommendations include sending letters to state committee chairs requesting that they consider adding medical nutrition therapy, and medically necessary obesity medication and bariatric surgery to the state’s list of essential health benefits plans must offer.
Del. Patrick Hope, D-Arlington, told the committee he wasn’t satisfied with sending letters to committees and proposed including the recommendations in a bill instead.
“I think we need to see it through and make sure that either it is acted upon at the committee level and send it to the floor and the governor, or we get a commitment from the chairs of those committees,” said Hope.
On eating disorders, the report recommends the state study the development of reimbursement rates for various types of treatment, ranging from residential to partial hospitalization and intensive outpatient options. It also recommends requiring both state-regulated and Medicaid providers to remove the need for patients to get prior authorization from their insurer to get coverage for eating disorder services.
Sens. Jennifer Boysko, D-Fairfax, and Siobhan Dunnavant, R-Henrico, both questioned why coverage for eating disorder services differ from coverage for other mental and behavioral health diagnoses under Medicaid when the treatments for both are very similar.
Obi-Tabot said “the rub happens when there are physical health needs for eating disorder treatment as well, so that can cause some confusion about how some services should be billed.”
Dunnavant suggested Virginia should refer to eating disorders solely as a mental health diagnosis.
“We have a real problem across the board with mental health and behavioral health, and we’ve got to fix it,” Dunnavant said.
