Lawmakers, Insurers Debate Obesity Surgery Coverage

Jacqueline Ezell says she felt as if she were drowning when she was rushed to the hospital four years ago. At 288 pounds, doctors had already diagnosed her with diabetes, glaucoma and high cholesterol, all side effects of obesity. She also had heart problems.

"I couldn't breathe," Ezell said.

Doctors gave Ezell two options. She could seek a heart transplant, or have gastric bypass surgery (search). She chose the surgery.

The Preston woman recently told Connecticut lawmakers that she went from a size 26 to a size 6. The surgery also helped lower her cholesterol (search), and she was taken off a heart transplant waiting list. Now, the only medications she needs are for her heart condition.

"There's nothing I can't do now," she said.

A proposal is before Connecticut lawmakers that would require insurance companies to cover the surgery for people with a body-mass index (search) of 30 or more if a doctor deems the surgery medically necessary. The BMI is a widely used formula based on height and weight.

The Connecticut proposal may not get off the ground this session because lawmakers are struggling to define under what medical conditions the surgery should be covered, said Sen. Joseph Crisco, a Woodbridge Democrat who chairs the legislative committee looking at the issue.

The debate is not unlike others across the country. Georgia lawmakers are considering a similar bill this year. And in Louisiana, 40 state employees were chosen last year from 1,200 applications to get the surgery on the state's dime.

The standard surgery, which can cost between $20,000 and $35,000, involves using staples to separate a small pouch at the stomach's top from the rest of the stomach, greatly limiting the amount of food that can be eaten. The procedure also involves bypassing much of the small intestine so that less food is absorbed into the body.

Blue Cross and Blue Shield of Alabama recently stopped paying for the operations while it decides how to handle claims; Blue Cross and Blue Shield of Florida has also decided to stop paying for the operation.

In Connecticut, many major plans offer coverage only for large numbers of employees. Others are considering offering the coverage for an additional charge.

"What we're starting to see is an increase in what we would consider at best, unnecessary, and at worst, unsafe, surgery," said Keith Stover, a lobbyist for the Connecticut Association of Health Plans. "Many plans decide the best course of action simply is to exclude coverage."

But many physicians say the long-term benefits of weight loss surgery outweigh the risk. Gastric bypass surgery can help cure obesity-related health problems such as high cholesterol, high blood pressure, sleep apnea (search) and even diabetes, said Dr. Jonathan Aranow, director of the Middlesex Hospital Center for Obesity Surgery.

It can also cut down on the long-term cost of medications, he said.

"The surgery pays for itself in under three years," he said. "There is no question that there are cost savings."

Last year the federal government opened the door for Medicare coverage of gastric bypass surgery.

But some lawmakers and insurers are also worried about risks. State Rep. Anthony D'Amelio, R-Waterbury, noted that two people in his district died after having the operation.

Complications strike as many as 1 in 5 patients having the surgery, and it is believed that for every 200 patients, 1 to 4 will die. Estimates are that more than 100,000 people will have the surgery this year.

"I would rather see people try to do it the harder way, exercise and eating properly," D'Amelio said. "I know it's a struggle ... I think it's the safest route."

But for some patients, the hard way hasn't worked.

Deborah Sicaras, 36, of Wethersfield, has tried Weight Watchers (search), Jenny Craig (search), diet pills and liquid diets (search); she also teaches ballet, tap and jazz four days a week.

"I'm one of the fortunate ones who will be able to have this surgery in the very near future," she said. "I can't do this by myself. I need assistance. I've dieted my whole life."