On April 5th, 2017, a bill was introduced to the House of Representatives by Representative Erik Paulsen (R-MN) with 150 cosponsors called H.R. 1953 the “Treat and Reduce Obesity Act 2017 to amend title XVII of the Social Security Act to provide for the coordination of programs to prevent and treat obesity, and for the other purposes” (H.R. 1953, 2017). This bill enhances the Social Security Act by allowing certified healthcare professional (advance nurse practitioners, physician assistants, registered dietitian, and physiologist) to provide intensive behavioral therapy along with obesity medication coverage in Medicare Part D (H.R. 1953, 2017). Advanced nurse practitioners were added to the certified healthcare professionals, which would be allowed to provide the therapy. Prior to the proposed amendment, only a physician could have prescribed the therapy. The therapy is going to be approved by the Secretary that is, “evidence-based, community-based lifestyle counseling program” (H.R. 1953, 21017). The medications under Part D are drugs that advanced nurse practitioners can already prescribe, but are just now covered under Part D.
Historical Environment
Obesity is becoming a common health problem, which in turn is starting to be extremely costly to the individual, population, and government. All fifty states and the District of Columbia have twenty percent of obese people in currently residing in them (https://stateofobesity.org/adult-obesity/, 2018). Some states are up to as much as thirty percent. The state with the highest percentage of obesity is West Virginia and the lowest is Colorado (https://stateofobesity.org/adult-obesity/, 2018). Each state has a tried to help regulate the obesity problem from drinking water, physical activities, health food initiatives and going as far as limiting screen in some states. These are just a few of the ideas that states have done. With obesity comes an extensive number of comorbidities such as: hypertension, hyperlipidemia, diabetes 2, sleep apnea, depression, coronary artery disease, osteoarthritis and there are many more. If an individual is treated for just these different diseases think about all the medication and resources that are involved. This also includes taking and all the costs of testing (labs, x-rays, MRI/CAT scans, studies (sleep and ultrasounds)) into consideration.
Sociocultural
For the longest time, people thought that obesity was a poor person disease. However, with the continuation of the growing trend of obesity, that theory might not hold true. Obesity can affect people by gender, ages, race, educational degrees, and income levels. “Hispanics (47.0%) and non-Hispanic blacks (46.8%) had the highest age-adjusted prevalence of obesity, followed by non-Hispanic whites (37.9%) and non-Hispanic Asians (12.7%)” (CDC, 2018). Multiple studies and the CDC have shown trend wise that the people with a higher education do not have obesity. That doesn’t mean there aren’t people with higher education that aren’t obese. Married adults tend to be more obsess compared to non-married adults. Males are less likely to be diagnosed with obesity compare to women. “Patients of lower socioeconomic status are also more likely to face other medical problems and social issues which may be given priority over recognizing obesity during ambulatory visits” (Miller, Stanistreet, Ruckdeschel, Nead, ; Fortuna, 2016, 1261-1262).
Ethical
As healthcare providers, we have the responsibility for personal autonomy, beneficence, and non-maleficence. Personal autonomy for a healthcare provider to allow our patients to function in an independent fashion, they can take our recommendations but it doesn’t mean they have to follow it. Healthcare providers act in beneficence for patients. We talk to patients about decreasing smoking cessation and glaze over the topic of weight. There is a fine line of being able to discuss with patients their weight without offending them. The fact that healthcare providers are to do no harm deliberately to patients is non-maleficence however, the patient can do harm to themselves. Also with all the recent social media regarding fat shaming and bullying, healthcare providers need to have an open and honest relationship with their patients regarding weight. But also healthcare providers need to have examine their thoughts and feeling regarding obesity before discussions with their patients regarding this issue. “For there will always be individuals who put their own health at risk voluntarily; out of their freely chosen and considered view that other things in life matter more to them” (Kniess, 2015, 889).
Economic
There has been a lot more money dropped in to the obesity whether it is from Insurance companies, Medicare, Medicaid, or Social Security. The money going into the drugs to cover the diseases that are commonly associated with obesity such as hypertension, hyperlipidemia, cardiovascular disease, diabetes, is extremely costly and detrimental to the economy. There is also an extensive amount of money to cover the counseling prior to bariatric surgery along with the coverage of the actual surgery. A study was in 2014 by Yang and Zhang that looked at obesity patients and the cost of on Medicaid in long-term care. Medicaid and Medicare are the two bigger players with patients in a long-term care. In the study they found that “women with higher BMIs at age 65 have high probability to enter LTC at a younger age, staying in LTC longer, and incurring high LTC cost reimbursed by Medicaid” (Yang and Zhang, 2014, 661). With patients going in heavier than normal, long-term care needs to get equipment to safety care for these patients. Yang and Zhang noted that these places have to absorb the cost since there isn’t any reimbursement to make sure that the obese patients are safely cared for (2014, 663). Since H. R. 1953 is focused on an amendment to Social Security, one needs to understand the timing of claiming Social Security. If a person is younger than or equal to sixty-two and claims Social Security, the monthly payment will be less than a person who is sixty-six and older. The older a person is and claims, the more Social Security the more money they get. Knoll, Shoffner, and O’Leary found that “obese individuals are at risk of receiving substantially reduced lifetime benefits if they have a reduced life expectancy” (2016, 728). This is from claiming Social Security on a younger age than normal. Knoll, Shoffner, and O’Leary also found that woman get a little bit larger percentage of benefits compare to men (2018). Two of the providers (healthcare and income) for older adults are seeing the impact obesity is making.
Political and Legislative
During President Obama’s presidency, First Wife Michelle had her Get up and Move campaign for childhood obesity. The goal was to get children moving along with eating fresh foods. Different states have purposed different legislation due to the obesity problem. New York had purposed a ban on soda. Other states laws that are being proposed regarding fighting off obesity is restrict soda and candy, making fast food restaurants post the sugar and fat contain on the menu. Some restaurants put the calories on the menus. So far though that isn’t working. For future proposals regarding legislation, Yang and Zhang want federal and state policy makers to keep in mind the obesity problem in mind when making Medicaid reform (2014, 663). Knoll, Shoffner, and O’Leary want “policymakers should consider the potential effects of obesity in their attempts to ensure the economic security of future older Americans, who are more likely to be obsess than today’s Social Security beneficiaries” (2018, 731). “Particularly important may be the indirect effects of obesity-that is, changes to claiming behavior-on the monthly benefits of future retirees (2018, 731).
Progression of the Bill
H.R. 1953 was introduced into the House of Representatives on April 5th, 2017 by Representative Erik Paulsen (R-MN) with 150 cosponsors. From the introduction the bill has went to the Committee on Energy and Commerce along the Committee on Ways and Means. Both of these committees have referred the bill to the Subcommittee on Health, which was on April 17, 2017 (congress.gov). From April 5th, 2017 to June 22, 2018 a total of 150 cosponsors have signed this bill. “Rep. Erik Paulsen (R-MN), Rep. Ron, Kind (D-WI), Rep. Grace Napolitano (D-CA), Rep. Ben Lujan (D-NM), Rep. Tony Cardenas (D-CA), Rep., Mark Pocan (D-WI), Rep. David Roe (R-TN), Rep. Denny Heck (D-WA), Rep. Scott Tipton (R-CO), Rep. David Young (R-IA), Rep. Earl Blumenauer (D-OR), Rep. Steve Cohen (D-TN), Rep. Ted Lieu (D-CA), Rep John Shimkus (R-IL), Rep. Peter DeFazio (D- OR), Rep. Brett Guthrie (R-KY), Rep. John Lewis (D-GA), Rep. James McGovern (D-MA), Rep. Lynn Jenkins (R-KS), Rep. Suzanne Bonamici (D-OR), Rep. Peter Roskam (R-IL), Rep. Susan Brooks (R-IN), Rep. Bill Pascrell (D-NJ), Rep. David Price (D-NC), Rep. Tim Ryan (OH-D), Rep. David Loebsack (D-IA), Rep. Patrick Meehan (R-PA), Rep Jim Costa (D-CA), Rep. Suzan DelBene (D-WA), Rep. Anna Eshoo (D-CA), Rep. Barbara Comstock (R-VA), Rep. Timothy Walz (D-MN), Rep. Eric Swalwell (D-CA), Rep. Bill Johnson (R-OH), Rep. Eliot Engel (D-NY), Rep. Albio Sires (D-NJ), Rep. James Langevin (D-RI), Rep. Don Young (R-AK), Rep. Derek Kilmer (D-WA), Rep. Vicky Hartzler (R-MO), Rep. Lucille Royal-Allard (D-CA), Rep. John Faso (R-NY), Rep. Robert Wittman (R-VA), Rep. Carol Shea-Porter (D-NH), Rep. Gerald Connolly (D-VA), Rep. Zoe Lofgren (D-CA), Rep. Seth Moulton (D-MA), Rep. Gwen Moore (D-WI), Rep. Rosa DeLauro (D-CT), Rep. Evan Jenkins (R-WV), Rep. Tim Murphy (R-PA), Rep. Kathleen Rice (D-NY), Rep. Scott Peters (D-CA), Rep. John Delaney (D-MD), Rep. Eleanor Norton (D-DC), Rep. Pramila Jayapal (D-WA), Rep. Mark Takano (D-CA), Rep. Kurt Schrader (D-OR), Rep. Yvette Clarke (D-CA), Rep. Daveid Scott (D-GA), Rep. Bill Foster (D-IL), Rep. Bobby Rush (D-IL), Rep. Bill Flores (R-TX), Rep. Donald Beyers (D-VA), Rep. Ed Perlmutter (D-CO), Rep. Bonnie Watson Coleman (D-NI), Rep. Lou Barletta (R-PA), Rep. Lee Zeldin (R-NY), Rep. Marsha Blackburn (R-TN), Rep. Blake Farenthold (R-TX), Rep. Marcia Fudge (D-OH), Rep. Brendan Boyle (D-PA), Rep. Cedric Richmond (D-LA), Rep. David Joyce (R-OH), Rep. Mike Kelly (R-PA), Rep. Pete Olson (R-TX), Rep. Keith Ellison (D-MN), Rep. Jeb Hensarling (R-TX), Rep. Don Bacon (R-NE), Rep. Jerry McNerney (D-CA), Rep. Matt Cartwright (D-PA), Rep. Anthony Brown (D-MD), Rep. Adam Kinzinger (R-IL), Rep. Morgan Griffith (R-VA), Rep. Thomas Suozzi (D-NY), Rep. Joyce Beatty (D-OH), Rep. Jamie Raskin (D-MD), Rep. Sam Johnson (R-TX), Rep. Joseph Kennedy III (D-MA), Rep. Terri Sewell (D-AL), Rep. Eddie Johnson (D-TX), Rep. Grace Meng (D-NY), Rep. Lisa Blunt Rochester (D-DE), Rep. Glenn Thompson (R-PA), Rep. Jacky Rosen (D-NV), Rep. Donald Norcross (D-NJ), Rep. Jason Smith (R-MO), Rep. Mike Coffman (R-CO), Rep. Steve Stivers (R-OH), Rep. Scott DesJarlais (R-TN), Rep. Frank LoBiondo (R-NJ), Rep. Peter King (R-NY), Rep. Gus Bilirakis (R-FL), Rep. Michael Turner (R-OH), Rep. George Holding (R-NC), Rep. Jimmy Panetta (D-CA), Rep. Christopher Smith (R-NJ), Rep. Michael Doyle (D-PA), Rep. Matt Gaetz (R-FL), Rep. Daniel Kildee (D-MI), Rep. Robert, Brady (D-PA), Rep. Julia Brownley (D-CA), Rep. Michael Conaway (R-TX), Rep. Mike Bishop (R-MI), Rep. David Rouzer (R-NC), Rep. Mark DeSaulnier (D-CA), Rep. Elizabeth Esty (D-CT), Rep. Sanford Bishop (D-GA), Rep. David Cicilline (D-RI), Rep. Kevin Cramer (R-ND), Rep. John Rutherford (R-FL), Rep. Raul Ruiz (D-CA), Rep. G.K. Butterfield (D-NC), Rep. Alcee Hastings (D-FL), Rep. Filemon Vela (D-TX), Rep. Ryan Costello (R-PA), Rep. Joseph Crowley (D-NY), Rep. Richard Hudson (R-NC), Rep. Sam Graves (R-MO), Rep. Stephen Lynch (D-MA), Rep. Doris Matsui (D-CA), Rep. Billy Long (R-MO), Rep. Alma Adams (D-NC), Rep. Carlos Curbelo (R-FL), Rep. Henry Johnson Jr. (D-GA), Rep. Mark Amodei (R-NV), Rep. Donald Payne (D-NJ), Rep. Bruce Westerman (R-AR), Rep. Vicente Gonzalez (D-TX), Rep. Ro Khanna (D-CA), Rep. William Keating (D-MA), Rep. John Katko (R-NY), Rep. Brian Higgins (D-NY), Rep. Will Hurd (R-TX), Rep. Adam Schiff (D-CA), Rep. Mo Brooks (R-AL), Rep. Chris Collins (R-NY), Rep Michelle Lujan Grisham (D-MN), Rep. Mike Quigley (D-IL), Rep. Brian Fitzpatrick (R-PA), Rep. Stephanie Murphy (D-FL), Rep. Emanuel Cleaver (D-MO), Rep. Leonard Lance (R-NJ), Rep Rodney Davis (R-IL), and Rep. Salud Carbajal (D-CA)” (Congress.gov). A total of 284 representatives have not signed the bill and couldn’t find any information against the Bill by those who have not signed it.
There is a bill S.830 “Treat and Reduce Obesity Act” in the Senate that was introduced by Senator Bill Cassidy (R-LA) on April 5th, 2017 that has nine co-sponsors (congress.gov, 2018). The co-sponsors are “Sen. Thomas Carper (D-DE), Sen. Chuck Grassley (R-IA), Sen. Christopher Coons (D-DE), Sen. Lisa Murkowski (R-AK), Sen. Martin Heinrich (D-NM), Sen. Shelley Moore Capito (R-WV), Sen. Amy Klobuchar (D-MN), Sen. Richard Burr (R-NC), Sen. Pat Roberts (R-KS) (congress.gov, 2018). This bill was introduced on April 5th and was also sent to the Senate Finance committee on the 5th of April as well (congress.gov, 2018).
Different organizations support this bill such as the Obesity Care Advocacy Network, whose members vary from Endocrine Society, American Gastroenterological Association, American Association of Nurse Practitioners, and the Academy of Nutrition and Dietetics. There is a petition going around on the internet against this bill, so far only eighty signatures have been collected. Considering that the bill has been in introduced and is now in the committees, which took twelve days, this bill could take another three to five years to pass. However, considering how much obesity is continuing to grow and cost the government and people, it might past within a year or two.
Effects of the bill
With any new legislation, there are going to be positive and negative effects on consumers. A positive effect for H.R. 1953 bill for providers is that many more people could get counseling/therapy for the obesity. Instead of just doctors, now dietitians, physical assistants, nurse practitioners, and psychologist can help the patient. A negative thing regarding this amendment is getting qualified providers who can provide the therapy. Getting a great evidence based plan that providers can agree on that is approved by the Secretary also is challenging. For the consumers, a positive benefit it that if they have a honest and open relationship with their provider they would be more willing to get therapy. A negative effect for the consumer is that patients could view this as an easy fix with Medicare Part D covering obesity medication, and not wanting to do the hard work that is still needed to fight obesity. For the government, a positive effect is there will be more therapy based counseling for patients, which will hopefully cost will go down after a few years that this law is passed. Some negative effects are that cost of obesity medication could go up, more people join Medicare Part D, or people do not use the therapy/counseling regarding their obesity. It is projected there will be more positives with the passage of this bill versus negatives.
Obesity in Australia
Australia another country that is struggling with an obesity problem around “sixty-three percent of adults are overweight or obese which is 11.2 million people” (https://renewbariatrics.com/australia-obesity-statistics/, 2018). “Australia is ranked number thirteen fattest country in the world behind the United States which is eight” (https://renewbariatrics.com/australia-obesity-statistics/, 2018). They are also spending a lot of money regarding healthcare just like the United States. Australia has also started coming up with ideas regarding on how to regulate obesity from childhood. Some of the ideas are putting on sugar tax, encouraging mothers to breastfeed, along with getting communities to put in parks, recreation spaces, and paths (https://renewbariatrics.com/australia-obesity-statistics/, 2018). Those ideas sound similar to what the United States is doing as well to help with the obesity issue. In an article by Hara, Taylor, and Barnes from (2015), they look at the ethical issues regarding the “war on obesity.” This article looked at weight loss initiatives and what the ethical values were. The conclusion is that that weight loss initiatives “were not reflective of the ethical values and principles of critical health promotion” (Hara, Taylor, Barnes, 2015, 246). The article made some good ethical points that every medical provider agrees to such as personal autonomy, non-maleficence, and beneficence.
Refining the measures or programs
A suggestion for the H.R. 1953 is to clarify who the Secretary is in the amendment. The first thought when that was read was the Secretary of State. It would be nice if it was the Surgeon General since the person in that position is typically a person who has worked in healthcare. The Surgeon General also understands evidence based care and along with what the medications for obesity do. Another suggestion for this bill is to also amend Medicare and Medicaid since those are two major healthcare insurances for older adults who get Social Security. If those healthcare insurances had therapy also, more people can be reached starting with children who are on Medicaid.
Conclusion
A bill for amendment of Social Security was admitted to the House of Representatives in April of 2017 with one hundred and fifty co-sponsors. There are some sociocultural, ethical, economic, political, and legislative issues that lead up to the bill. As this bill continues to slowly move through the House of Representatives, may many more Representatives sign on to this bill. This bill has potential to help many patients’ in reaching their optimal health.
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