Morbidly obese young adults ages 18 to 20 will be eligible for state-paid surgery for weight loss starting next year, under new rules approved by a Washington health care committee.
However, the group responsible for determining Medicaid and other coverage denied the procedure for use in children and younger adolescents, citing safety concerns and worries about whether they could consent to life-altering surgery.
“It’s a lot to be deciding on when you’re not quite an adult,” said Dr. Matthew Rawlins, a Spokane bariatric surgeon.
“This still needs to be the last resort. This needs to be the thing tried after lifestyle maximizations have been tried and failed.”
Rawlins and other weight-loss surgeons in the Inland Northwest and across the Washington said they supported the new coverage, which makes the state among the first in the nation to adopt rules expanding payment for the $25,000 procedure for people younger than 21.
It’s an important step, they noted, in a country where 30 percent of people under 20 are overweight or obese and one in 50 adults is morbidly obese – about 100 pounds overweight.
“There’s a role for adolescent surgery in a subset of people,” said Dr. John Pennings, a Post Falls bariatric surgeon who treats many Washington clients. “The reason people don’t get the care is lack of access,” he added.
One Spokane teenager whose family sold a business to pay for his surgery had high praise for the move that would make the procedure more accessible.
“I think that is really cool,” said Bob Plumb, 17, a Central Valley High School senior who lost 200 pounds after a gastric banding operation in 2005. “I’ve seen how it’s changed my life. There are so many young people who would be interested in this surgery if it’s available to them.”
An estimated 43,000 18- to 20-year-olds are covered by Washington Medicaid and Uniform Medical Plans, said Leah Hole-Curry, director of the state’s Health Technology Assessment program.
In a state where 11 percent of adolescents are overweight and 2.5 percent are believed to be morbidly obese, that means Washington could expect nearly 1,100 young people in that age range to be eligible for surgery under the new rules, she said.
Candidates must meet the same criteria as older bariatric patients. They must be severely overweight, with a BMI – body mass index – greater than 40, or greater than 35 with at least one serious weight-related illness such as diabetes or heart disease. (A BMI of 35 is the equivalent of being 70 to 80 pounds over ideal weight, while a BMI of 40 is about 100 pounds overweight.)
The Washington rules also limit the procedure to one surgery regarded as less invasive than others: laparoscopic adjustable gastric banding. That involves an operation that places a band around the upper portion of the stomach to limit the amount of food it can hold.
“It’s like a prosthetic ‘full’ button,” said Liz Plumb, 47, Bob’s mother. She and her husband, Scott, 45, also had the surgery. “Some of us are born without full buttons.”
The point is to ensure that the surgery is a medical necessity, said Dr. Jeffrey Hunter, director of the bariatric surgery program at Virginia Mason Hospital and Medical Center in Seattle.
Not everyone who’s eligible for the procedure will be accepted, Hunter noted. All patients, but especially younger patients, must receive psychological evaluation and counseling before undergoing weight-loss surgery.
“It’s about health; it’s not cosmetic,” said Hunter, who performs 15 to 20 surgeries a month, including many on patients in their early 20s.
Bariatric surgery has been shown in studies to dramatically reduce or eliminate Type 2 diabetes, hypertension, sleep apnea and high cholesterol levels in nearly 90 percent of patients.
The Washington ruling nixes coverage for those under 18 because of concerns that the procedure might be too dangerous for growing bodies and that kids aren’t equipped to agree to the massive lifestyle changes required.
“I think it would be fair to say the highest concern was safety,” said Hole-Curry.
But one bariatric industry expert said Washington officials were being overly cautious in denying coverage to younger patients.
“It’s unfortunate that the state of Washington has chosen that position,” said Dr. Harvey J. Sugerman, past president of the American Society for Bariatric Surgery.
Long-term studies have shown that the surgery can be safe and effective in adolescence, a time when life-changing surgery might be particularly necessary.
“These kids are as troubled, if not more troubled, than adults,” he said.
As the incidence of obesity increases at younger and younger ages, surgery to solve the most severe cases is inevitable, Sugerman and others said.
Whether government should foot the bill is a question for many, doctors said. There’s often a mistaken perception that very overweight people should just try harder, Sugerman said.
“It’s the standard prejudice against any group of people, particularly the obese,” he said.
But when health is at stake, there’s no question government and other insurers should pay.
“If it ought to be done by anyone, the state ought to be willing to cover it,” said Rawlins of the Rockwood Bariatrics Clinic. “In the long run, it’s going to save money and lead to healthier lifestyles.”