REDEFINING EATING DISORDERS IN AMERICA:

A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

Redefining Eating Disorders in

America: A Proposed Policy for
Expanding Insurance Coverage
Juliette van Schaik
CAS 138T 004
April 14, 2017
REDEFINING EATING DISORDERS IN AMERICA:
A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

Eating disorders continually rank among the leading causes of death worldwide;

eating disorders like anorexia nervosa, bulimia nervosa, and binge eating disorder (or

BED) kill someone at least once every 62 minutes (Eating Disorders Coalition, 2017).

The National Eating Disorder Coalition reports that improperly treated eating disorders

have the highest CMR (crude mortality rate) of any mental illness, with up to 20 percent

of sufferers dying of the disease. The past decade has seen overwhelming strides in the

understanding and treatment of eating disorders; yet, despite these advances, their

prevalence in the United States remains indisputable. An estimated 30 million Americans

will battle an eating disorder in their lifetime; of these, only 2 percent will ever be

appropriately treated (Mirasol, 2017), largely because of inadequate coverage by

insurance companies.

These alarming incidence and mortality rates can in part be contributed to the

multifaceted nature of eating disorders, namely that they are psychologically-based

illnesses often manifesting in physical symptoms. Unfortunately, the severity of these

physical symptoms is far from uncommon; eating disorder patients can develop

osteoporosis, kidney failure, and heart attacks all of which are direct results of the

underlying, psychological issues. Many eating disorder patients need these issues

addressed immediately to prevent a worsened condition or death. However, since the

eating disorder is causing these tangible, medical problems, the patients physical state is

unlikely to fully or permanently improve without addressing the psychological.

Yet, the latest edition of the Diagnostic and Statistical Manual of Mental

Disorders (or DSM-V) a comprehensive book published by the American Psychiatric

REDEFINING EATING DISORDERS IN AMERICA:
A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

Association (APA) and referenced in diagnosing mental disorders worldwide requires

an individual to be of significantly abnormal weight to be diagnosed with many of

several, distinct eating disorders. For example, someone must be of a significantly low

body weight in the context of age, sex, developmental trajectory, and physical health

(Sheppard Pratt Center, 2015) as per the DSM-V to be diagnosed with anorexia nervosa.

We are conditioned to think that the key feature of anorexia nervosa is low BMI but in

fact, we miss a lot of eating disorders when focusing primarily on weight (Bulik, 2014).

Although further diagnostic criteria address the psychological components of the disease,

it does not change the fact that someone must be underweight to technically be anorexic.

This causes issues once an individual is weight-restored (i.e., once they have reached an

appropriate BMI), because they no longer meet the criteria for a diagnosis of anorexia.

If the individual is still mentally ill upon weight restoration which she generally

is she will be re-diagnosed, this time with Other Specified Feeding or Eating Disorder,

or OSFED. The DSM-V defines an OSFED diagnoses in context of other eating

disorders, and makes the claim that people with OSFED exhibit symptoms of anorexia,

bulimia, or BED without neatly fitting into one of those diagnostic categories. For

instance, someone may earn an OSFED diagnosis if all criteria for anorexia nervosa are

met; despite significant weight loss. Because of how it is defined, OSFED is sometimes

interpreted as a subclinical or sub-threshold diagnosis. This can be misleading in terms

of severity (Sheppard Pratt Center, 2015). Although the symptoms associated with

OSFED are generally less apparent i.e., an individuals weight loss or gain will be less

drastic because of the inconsistency of her eating patterns it is associated with an

REDEFINING EATING DISORDERS IN AMERICA:
A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

annual mortality rate of 5.2%; for reference, the CMR of anorexia nervosa hovers at 4.0%

(Crow et al., 2009).

Annetta Ramsay, Ph.D., has spent the last 30 years fighting for eating disorder

patients. She notes that insurance sometimes agrees to pay and then they dont, or they

terminate care abruptly, especially when someone is diagnosed with OSFED instead of

one of the main eating disorders. About 80% of the individuals who have accessed

care for their eating disorders do not get the intensity of treatment they need to stay in

recovery they are often sent home weeks earlier than the recommended stay [because of

the lack of insurance coverage] (South Carolina Department of Mental Health, 2006). In

2009, the Mental Health Parity and Addiction Equity Act (MHPAEA) modified a pre-

existing bill requiring parity in aggregate lifetime and annual dollar limits for mental

health benefits and medical/surgical benefits so that it also applied to substance use

disorders (Federal Registrar, 2013). Although the MHPAEA effectively increased the

coverage of multiple mental illnesses, it made no such provisions regarding the treatment

of eating disorders. This allows insurance companies to treat eating disorder patients

irregularly, expending resources as they feel fit and leaving many vastly underinsured and

undertreated.

In the rare cases when an insurance company agrees to pay for treatment, a full

stay in a residential facility can still cost the families of patients more than $25,000 out of

pocket (Ramsay, 2015). When families cannot afford care, they are often forced to take

drastic financial measures to stay out of debt; many, for example, report taking on three

jobs at a time, spending retirement or college funds, and/or putting mortgages on their
REDEFINING EATING DISORDERS IN AMERICA:
A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

homes. Even then, it is inevitable that, without the aid of insurance, treatment will be

terminated.

The problem here is twofold. Since many eating disorder diagnoses (namely those

for anorexia and BED) require a certain BMI, the diagnosis dissipates or changes to

OSFED with weight restoration. This gives the faade that the patient is completely

healed when, in reality, only the physical has been resolved; the psychological, driving

force behind the eating disorder is still active. Since [B]oth public and private health

insurance plans are designed to stringently limit coverage of eating disorders by treating

mental illnesses differently from physical illnesses, and by setting conservative criteria

for qualification (Hewitt, 2013), there remains a discrepancy between those who need

insurance coverage for treatment and those who receive it. The lack of regulations

concerning the coverage of eating disorder treatment allows insurance companies to

terminate coverage once they deem the patient healthy enough.

To achieve more comprehensive insurance coverage of eating disorder treatment,

a multi-step plan which targets diagnostic criteria while seeking legislative action needs

to be enacted.

When an eating disorder becomes severe, someone usually begins to exhibit

physical side-effects. These can range in expression and severity; for example, one

anorexic may only experience mild anemia, while another may struggle with seizures. So,

too, is the case with weight; that is, someone with anorexia may only be a few pounds

underweight or still at an appropriate weight. The behavioral patterns associated with

REDEFINING EATING DISORDERS IN AMERICA:
A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

eating disorders abnormal food intake, exaggerated concern with body image or weight,

etc. are the true symptoms of the disease; the physical state of the individual is merely a

reflection of a psychiatric illness. Mayo Clinic psychologist Leslie Sim remarked that

[W]e see people who have all the psychological, behavioral, cognitive and physical

symptoms of anorexia nervosa, but the only difference is their weight (Haelle, 2014). In

the physiological world, symptoms are used to help doctors make a diagnosis; but the

absence of one or more symptoms does not disqualify a diagnosis. Lung cancer, for

example, is typically expected when a patient begins to cough up blood. However, the

absence of this cough does not mean someone cant have lung cancer, and its presence

does not imply cancer; further testing has to be performed in both scenarios before a

doctor can conclusively diagnose someone (Mayo Clinic, 2015). Why, then, is it

appropriate for an eating disorder diagnosis to be contingent upon a single criteria

abnormal BMI that isnt even consistent in all who are sick?

Restructuring the criteria for eating disorder diagnoses from what is currently

defined in the DSM-V is the first step that needs to be taken. I am proposing that an

individuals weight no longer be used in official diagnosis; instead, all physical

conditions an eating disorder patient may experience will be moved into the symptom

category. This way, anything physical would be used as clues to guide a psychologist to

the proper diagnosis, working in conjunction with the presence of other symptoms to

indicate the true problem, rather than serving as a necessity for diagnosis.

The benefits of this slight modification are multifold. Firstly, it would help more

people receive proper diagnosis. While OSFED is a legitimate diagnosis in many cases
REDEFINING EATING DISORDERS IN AMERICA:
A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

for instance, if someone routinely binges and proceeds to restrict their food intake

shifting the diagnostic criteria away from the physical would prevent weight-restored

anorexics from being misdiagnosed. Preventing misdiagnosis is crucial in determining

the correct course of treatment, which helps clinicians to better address the true,

psychological issues of their patients. Ideally, a larger majority of people would be

correctly diagnosed and properly treated for their disorder; overtime, this will speed and

strengthen the recovery process.

While this helps resolve the issue of misdiagnosis, it does not address how

insurance companies view OSFED. Since, currently, many eating disorder sufferers are

improperly diagnosed with OSFED based on their weight, we would see a decrease in

patients included in this diagnostic category. However, simply changing the physical

diagnostic criteria will not convince insurance companies of the severity of OSFED and

its legitimacy as an eating disorder. It is not enough, therefore, to simply do away with

the physiological components of other eating disorder diagnoses; the definition of

OSFED has to be changed as well. As discussed above, OSFED is defined in terms of

many other, seemingly more legitimate, eating disorders. This can be misleading in

terms of severity (Sheppard Pratt Center, 2015). In order to prevent OSFED from being

viewed as less legitimate than the main eating disorders, we must reallocate diagnostic

criteria such that it stands on its own; that is, OSFED should no longer be referred to as

atypical anorexia or bulimia, but as its own, distinct disorder. This will ensure that

more people are correctly diagnosed and that no eating disorder is unintentionally

interpreted as less severe than another.

REDEFINING EATING DISORDERS IN AMERICA:
A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

Finally, further legislative action must be taken. Prior to the modifications made

by the MHPAEA, 66% of insurance plans had quantitative treatment limits (QTLs)

regarding mental and/or substance abuse disorders, meaning that millions of Americans

had dollar limits imposed on the amount of mental health treatment they could receive

Postimplementation, virtually all plans dropped such limits, suggesting that MHPAEA

was effective at eliminating QTLs (Thalmayer et al., 2016). This drastically increased

the availability of treatment for individuals suffering from addiction or other mental

health issues. Unfortunately, the MHPAEA completely neglects eating disorders,

presenting the same problem (lack of insurance coverage) that was previously seen for

substance abuse.

Since the MHPAEA has been irrefutably successful in drastically increasing the

availability of insurance coverage for a variety of mental disorders, I propose that it be

further modified. The amendments will be similar to those the MHPAEA imposed on the

MHPA, ensuring that the QTLs imposed on the treatment of eating disorders be under the

same regulations as surgical, medical, and addiction treatments currently are.

Of course, there are potential shortcomings with the proposed policy that must be

acknowledged. It is possible that the MHPAEA will be weakened in the upcoming

months or years. Although passed prior to 2010, it has been greatly enhanced by the

Affordable Care Act (ACA), which gives more Americans access to healthcare, includes

these disorders in the Essential Health and Benefits, and applies federal parity protections

to mental health and substance use disorders, (Beronio et al., 2013). Yet, President Trump
REDEFINING EATING DISORDERS IN AMERICA:
A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

has made it clear that he plans to repeal the ACA and replace it with his own version. It is

unclear what his plan entails, but obvious that, if not done properly, repealing the ACA

will undermine the MHPAEA and make it more difficult for future amendments to be

truly successful. Making the proposed changes to the MHPAEA, however, will still help

those with access to insurance get proper coverage for eating disorder treatment, even if

its efficacy is somewhat reduced.

Furthermore, the DSM has only been updated four times since its initial release in

1952, averaging over 16 years for new diagnostic criteria to be incorporated into and

published in the world-renowned manual (American Psychiatric Association, 2017).

Since the DSM-V was published in 2013, we can expect at least a decade before the

weight-related diagnostic criteria for anorexia are eliminated and the definition of

OSFED is reframed. During this time, untold millions of Americans could continue to be

misdiagnosed. The APA, however, could take intermediate action by releasing a

statement of intent which would advertise the planned modifications to the DSM.

Although such a statement would not be as influential as the reprinting of the DSM, it

would have a more immediate impact as psychologists begin to adhere to the proposed

guidelines.

The prevalence of eating disorders in the United States is undeniable, and many

experts conclude that the issue is in large part caused by the lack of insurance coverage

for these disorders, which makes treatment unaffordable and reduces proper access to
REDEFINING EATING DISORDERS IN AMERICA:
A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

care. To combat this exigence, I propose the execution of a plan which restructures the

DSM criteria for eating disorder diagnoses and amends the MHPAEA to extend

availability of treatment to patients suffering from these mental illnesses.

REDEFINING EATING DISORDERS IN AMERICA:
A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

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A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

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REDEFINING EATING DISORDERS IN AMERICA:
A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

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A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

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A PROPOSED POLICY FOR EXPANDING INSURANCE COVERAGE

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