The politics of obesity and Medicare

A good summary by Jon Bonné of MSNBC points out that the much-ballyhooed change in Medicare policy amounts to somewhat less than a hill of beans in treatment coverage. The upshot, it turns out, is that a lone sentence will be removed from the Coverage Issues Manual (which details what is covered by the agency): “Obesity itself cannot be considered an illness.” No treatments will be explicitly added to the manual as eligible.

But here's a strange twist. There is, in fact, one treatment for obesity which is up for consideration. Not the friendlier, cheaper, possibly more effective (and certainly more sensical, from a public-health standpoint) anti-obesity treatments called diet, exercise, and nutrition, but fantastically expensive gastric surgery! Bonné writes:

The Medicare Coverage Advisory Committee, which recommends what the agency should pay for, may consider bariatric surgery this fall. But the agency has not scheduled discussion of other, less drastic treatments, such as nutrition counseling and structured weight-loss programs, though Tunis told MSNBC.com those treatments could be considered if the agency is asked to review them by outside petitioners.

Stranger still, the technical assessment (TA) mentioned in the article, a solid review of the epidemiologic evidence ("Diagnosis and Treatment of Obesity in the Elderly"), actually focuses on such treatment programs, which try to encourage voluntary weight loss. To quote the TA:

Obesity therapies with good evidence for improving health outcomes in the elderly incorporate both dietary and behavioral components; therefore, we consider these modes jointly here. All successful studies included exercise and used intensive counseling protocols. Effective interventions typically used diets based on reduced caloric intake, often in the setting of low-saturated-fat and low-cholesterol intake goals. . . . Weight loss showed clinical utility, particularly for cardiovascular-related benefits such as oral glucose tolerance testing or diabetes incidence.

Which "outside petitioners" got bariatric surgery on the agenda while treatment programs are not? Do the obesity groups prefer one treatment to another, and why? I would hope that the relevant petitioners (maybe I'll find out who they are) will approach the bar and ask that public health be covered before surgery.