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In a keynote address to researchers and public health officials this morning, Health and Human Services secretary Kathleen Sebelius promised that she and President Obama "are committed to delivering a health care system that provides Americans with better quality and lower costs. And fighting obesity is at the heart of both of those goals."   Someone might want to let Congress know that. There are very few targeted anti-obesity programs in the House and Senate drafts released so far. And promised changes to the delivery mechanisms of health care have yet to materialize. Here is what (probably) will be done: insurers have the ability to raise premiums on the basis of pre-existing conditions on obesity.

Few of them do, although there is plenty of evidence that obese people wind up taking home less money from their employers because employers are paying more for their health care.  Both the House and the Senate bills would prohibit insurance companies from denying coverage to anyone based on a pre-existing condition and would prevent scaled premiums on the basis of body weight. This change may well help reverse the damaging and physically harmful stigma that fat people fact, but it will not effect on obesity. It remains to be seen whether the government will give the insurance companies more flexibility to experiment with ideas like rewarding obese people with even lower premiums if they begin and maintain a weight loss program.  Until 2004, Medicare refused to classify obesity as an illness and wouldn't reimburse people for interventions directly related to obesity. In effect,  before that change, wealthier people had access to better obesity prevention options than poorer people. That status quo exists in roughly the same measure today, although Medicare is covering more obesity-related services than it did. In 2006, Medicare followed the practices of private insurers and began to cover bariatric surgery procedures for the morbidly obese. Still, the private and public health insurance systems are spotty when it comes to treatments that prevent people from having to reach the surgery stage. Some states pay for weight loss counseling; others don't. Some states reimburse people who seek help from a nutritionist. Others don't. As a cost issue, both Medicare and Medicaid spend about $1600 more per obese person than they do on someone with a normal weight. Since there is a strong correlation between poverty and obesity, Medicaid and Medicare have born the brunt of the rise in obesity costs; even they cover comparatively fewer Americans than private plans, they pay for half of all costs associated with obesity.  It's not fashionable to admit this these days, but if private insurance companies are going to be the mediator between most Americans and their employers, and the employer-employee interaction is where a new incentive structure can be created to help reduce costs. Whether Medicare and Medicaid are thusly empowered is a different question, although there are signs that all insurance platforms, be they public or private, will be required to beef up their coverage of comprehensive preventative primary care, which should, in theory, include better obesity monitoring and prevention. In terms of changing the obesogenic environment and the physical geography of health care, the early 2009 stimulus package included a variety of inducements. Sebelius announced today that part of $1 billion appropriated for disease prevention would be spent on obesity programs, kind of a drop in the bucket.