Just read this

[Guest guest]

Hey guys this is a little long, but i think very important...It means that

slowly but surely we are winning the insurance war.

Robynn

NEWS-PRESS STAFF WRITER

Since undergoing gastric bypass surgery in March, Debbie has

lost 40 pounds and has hopes

of losing 135 more. Last week, she was overjoyed to discover she

could

paint her toenails, a simple task

she's been unable to do for years.

At 5 feet, 7 inches and 330 pounds, was able to get the

operation -- also known as

stomach stapling -- only after filing a lawsuit against the state

Department of Health, which

had denied her request through Medi-Cal, California's health program

for low-income, needy people.

But ' victory, hard-won after a two-year battle, is viewed as

significant for Medi-Cal patients who are more than 100 pounds

overweight

and could benefit from the surgery, if a doctor determines it is

medically

necessary.

News of the settlement in the case also has been shared with public

interest

law firms around the state, potentially opening the door for other

low-income people to obtain the procedure.

In the past 10 years, said she had tried everything to lose

weight,

including exercise, diets and prescription drugs. She would lose a

little, and

then get stuck.

It was hard to celebrate losing 5 pounds when she knew she needed to

lose

170 more, a task that seemed insurmountable. would slip up on

her

diet and was endlessly starting again " tomorrow. "

And the needle on her scale went up and up and up.

" It was like taking a spoon to a mountain in order to move it, " said

,

a single mother who works two jobs and is studying radiology at City

College. She plans to become an ultrasound technician.

" This is not something that someone should go through lightly, "

said. " It is a very big step to take, and it is not recommended for

everybody. But I felt in my heart it was something I should pursue.

I

asked

God to help me, if it was the right thing. "

' lawsuit sought to overturn Medi-Cal's refusal to authorize

the

bypass surgery. The state settled in ' favor in March and she

had the

operation later that month.

" This is a real health issue, not a moral failing, as obesity has

been

seen in

the past, " said attorney Kirk Ah Tye of Channel Counties Legal

Services

Association, the Santa Barbara public interest law firm that handled

'

case.

" The state held an outmoded view of surgical procedures for obesity. "

' physicians recommended the gastric bypass operation for her

on

grounds it was medically necessary to prevent early death and to

address

her arthritis, high blood pressure, bursitis, heart palpitations,

shortness of

breath, bladder problems and back pain.

For the first time in years, said she has hope that she can

succeed in

her weight loss. In addition to feeling better physically, she hopes

her

struggle can help her become a better health care professional.

" How serious is someone going to take a big fat person in the job

market? "

asked. " I want to reach my potential, and I think people will

pay

more attention if you have your health.

" I hope I can be of more help to people because I have overcome

something

that defeated me in my life. "

In court documents, Ah Tye argued that Medi-Cal's denial of a gastric

bypass operation for amounted to an unlawful " underground

regulation " that essentially discriminated against obese people.

As a part of the settlement, Medi-Cal established new, less

restrictive

criteria for determining qualification for the procedure in '

case. It

remains to be seen whether the new criteria will be applied

throughout

the

state.

Authorities from the state Department of Health Care Services in

Sacramento could not be reached Wednesday for comment about the

settlement or how they plan to handle future cases.

Gastric bypass surgery, also known as bariatric surgery and stomach

stapling, reduces the capacity of the stomach to just a few ounces.

The

procedure has been refined in recent years and has become more widely

prescribed since the National Institutes for Health in 1991 endorsed

it as

one option for treating certain patients. The procedure forces a

change in

eating habits because indulging in more than just a few bites will

make a

person feel sick.

In addition to its potential for changing who might be allowed the

procedure, the case illustrates that it is becoming

increasingly

important for doctors, sometimes with the intervention of lawyers, to

actively lobby on behalf of patients' medical needs, experts say.

" The fact that this procedure was deemed 'medically necessary' by her

doctors is the key, " said UCSB lecturer Kohl, a medical ethics

specialist.

" With insurance and managed care the way it is, patients have to be

more

assertive and knowledgeable, and doctors have to act more like

advocates

for patients. "

The case also shows how some medical problems, like being overweight,

are viewed as less deserving of treatment than other maladies, such

as

cancer. But that seems to be changing. Obesity is increasingly

viewed

as a

disease, and research shows that genes may play a role in who is

affected.

Medi-Cal historically has denied gastric bypass surgery on grounds

that it is

" unacceptable as an alternative to medical treatment due to

long-term

risks

..Ê.Ê. high rate of treatment failure, and the likelihood of

abuse, "

according

to court documents.

' request for coverage of the procedure also was denied

because

her

weight problem did not present an imminent threat of death or

prevent

her

from working -- strict criteria not used to approve treatment for

other health

problems.

" We need to ask if the person is suffering medically and if

something

can

be done to improve health, and then we have an obligation to address

that, "

Kohl said.

" We really can't get caught up in judging people. That does not mean,

however, that you should ignore behavior that leads to health

problems.

Those issues have to be addressed, too. But this could be an

important

first

step. "

Obesity is a growing problem in the United States, with one in five

people

classified as obese -- being more than 30 percent overweight.

Additionally,

health experts say 95 percent of diets fail because keeping the

weight

off

requires changes in eating and exercise habits.

--------------------------------------------------------------------------------

--------------------------------------------------------------------------------